Echocardiography In Intensive Care Unit Research Articles

Echocardiography in Intensive Care Unit: Do We Need a Certification Program?

Echocardiography in Intensive Care Unit: Do We Need a Certification Program?

Echocardiography in Intensive Care Unit: We Need a Certification Program

Echocardiography in Intensive Care Unit: We Need a Certification Program

Unexpected systolic anterior motion of the mitral valve-related hypoxemia during transurethral resection of the prostate under spinal anesthesia: a case report

BackgroundDynamic obstruction of the left ventricular outflow tract resulting from systolic anterior motion of the mitral valve can be an unexpected cause of acute and severe perioperative hypotension in noncardiac surgery. We report a patient undergoing spinal anesthesia for transurethral resection of the prostate who experienced sudden hypoxemia caused by systolic anterior motion-induced mitral regurgitation but with a clinically picture simulating fluid overload.Case presentationAn 83-year-old man with a history of hypertension was scheduled for transurethral resection of the prostate. One hour after spinal anesthesia, he developed acute restlessness and dyspnea, with pink frothy sputum and progressive hypoxemia. Slight hypertension was noted, and an electrocardiogram showed atrial fibrillation with a rapid ventricular response. Furosemide and nitroglycerin were thus administered for suspected fluid overload or transurethral resection of the prostate syndrome; however, he then became severely hypotensive. After tracheal intubation, intraoperative transesophageal echocardiography was promptly performed, which revealed an empty hypercontractile left ventricle, significant mitral regurgitation and mosaic flow signal in the left ventricular outflow tract. Following aggressive fluid therapy, his hemodynamic changes stabilized. Repeat echocardiography in intensive care unit confirmed the presence of systolic anterior motion of the anterior mitral leaflet obstructing the left ventricular outflow tract. We speculate that pulmonary edema was induced by systolic anterior motion-associated mitral regurgitation and rapid atrial fibrillation, and the initial management had worsened his hypovolemia and provoked left ventricular outflow tract obstruction and hemodynamic instability.ConclusionsPulmonary edema caused by systolic anterior motion of the mitral valve can be difficult to clinically differentiate from that induced by fluid overload. Therefore, bedside echocardiography is paramount for timely diagnosis and prompt initiation of appropriate therapy in the perioperative care setting.

Induction and deduction in sepsis-induced cardiomyopathy: five typical categories

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. The heart is one of the most important oxygen delivery organs, and dysfunction significantly increases the mortality of the body. Hence, the heart has been studied in sepsis for over half a century. However, the definition of sepsis-induced cardiomyopathy is not unified yet, and the conventional conception seems outdated: left ventricular systolic dysfunction (LVSD) along with enlargement of the left ventricle, recovering in 7 to 10 days. With the application of echocardiography in intensive care units, not only LVSD but also left ventricular diastolic dysfunction, right ventricular dysfunction, and even diffuse ventricular dysfunction have been seen. The recognition of sepsis-induced cardiomyopathy is gradually becoming complete, although our understanding of it is not deep, which has made the diagnosis and treatment stagnate. In this review, we summarize the research on sepsis-induced cardiomyopathy. Women and young people with septic cardiomyopathy are more likely to have LVSD, which may have the same mechanism as stress cardiomyopathy. Elderly people with ischemic cardiomyopathy and hypertension tend to have left ventricular diastolic dysfunction. Patients with mechanical ventilation, acute respiratory distress syndrome or other complications of increased right ventricular afterload mostly have right ventricular dysfunction. Diffuse cardiac dysfunction has also been shown in some studies; patients with mixed or co-existing cardiac dysfunction are more common, theoretically. Thus, understanding the pathophysiology of sepsis-induced cardiomyopathy from the perspective of critical care echocardiography is essential.

Training in POCUS echocardiography for intensivists

Point of care ultrasound (POCUS) Echocardiography is an essential non-invasive, bed-side imaging tool for managing patients in the intensive care unit (ICU). In ICU literature, POCUS echocardiography refers to focused echocardiography, basic echocardiography, and level 1 echocardiography. This approach mainly uses 2D ultrasound, and the primary goal of POCUS Echocardiography is to evaluate the cause of shock by answering a few critical questions about the cardiac structure and function. Currently, many international and national guidelines for POCUS echo in ICU exist. The Australia and New Zealand College of Intensive Care Medicine has made POCUS echocardiography learning a necessary component of training since 2014. However, it continues to be a significant challenge to learn POCUS echocardiography in ICU. This challenge is not only for current trainees but also for consultants who trained in the era when POCUS machines were not readily available at the bedside. Echocardiography image acquisition, unlike other skills, requires consistent, supervised, and deliberate practice to master. Not just image acquisition, but also the interpretation of findings in the clinical context is important. An ICU trainee or consultant who wants to learn echocardiography has several challenges to overcome during their journey of learning POCUS echocardiography. First and foremost is organizing the time in the busy clinical work to learn echocardiography. The second one is finding a supervisor as the availability of supervisors is limited in many ICUs. The third challenge is to get the basic views as patients in ICU have difficult acoustic windows due to mechanical ventilation, positioning restrictions, chest drains, and ECG leads. The fourth challenge is to put the findings on echocardiography in the clinical context to come up with a management plan. On the other hand, the main problem for supervisors of POC echocardiography is to keep the trainee's enthusiasm throughout their learning as the learning can be quite frustrating, especially at the beginning of the learning curve. This main aim of the current presentation is to summarise various educational techniques that a trainee and supervisor can use to make the echocardiography learning easy. The talk will discuss the current guidelines, issues with the current teaching methodologies, and about the novel ways of teaching POCUS Echocardiography (for example, simulators).

Utilization of echocardiography in Intensive Care Units: results of an online survey in Germany.

In patients with hemodynamic instability echocardiography has been recommended as the preferred modality to evaluate the underlying pathophysiology. However, due to the fact that recent scientific data on the utilization of echocardiography in German Intensive Care Units (ICU) are scarce, we sought to investigate current practice. A structured, web-based, anonymized survey was performed from May until July 2015 among members of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) consisting of 14 questions. Descriptive data analysis was performed. One hundred four intensivists participated in the survey. Two-thirds of participants (66%) used echocardiography regularly for hemodynamic monitoring and stated that it changed the therapy in 26-50% of the cases irrespective of the time performed after ordering the examination. Transthoracic (TTE) were more frequently used than transesophageal (TEE) examinations. Twenty-six percent of the participants held an echocardiography certificate with a formal examination, 27% completed a structured training without an examination and almost half of the questioned ICU personnel (47%) did not complete a comprehensive training. The results of this survey demonstrate a widespread utilization of echocardiography as part of routine diagnostic on frequent number of operative ICUs. However, there might be a lack of structured echocardiographic training especially for anesthesiologists.

Competence of Intensivists in Focused Transthoracic Echocardiography in Intensive Care Unit: A Prospective Observational Study.

Objectives:Focused transthoracic echocardiography (fTTE) in critical care can be used to assess patient's volume status, ventricular contractility, right ventricle chamber size, and valvular abnormalities. The objective of the study was to assess the competency of intensivists in performing fTTE in Intensive Care Unit (ICU) patients after a brief training course by cardiologist using a specific ECHO protocol.Methods:One hundred and four patients in ICU were recruited for this prospective observational study over a period of 12 months. Intensivists were trained for 60 h (2 h/day for 30 days). Intensivists performed fTTE in 82 ICU patients using a specific ECHO protocol developed in consensus with cardiologists. Each patient was assessed by an intensivist and two blinded cardiologists. At the end of the study period, the competency of intensivists was compared with two cardiologists and analyzed using intraclass correlation coefficient (ICC).Results:There were excellent agreement between intensivists and cardiologists in terms of measuring ejection fraction (ICC estimate was 0.973–0.987), valvular function (ICC estimate for mitral valve was 0.940–0.972; ICC estimate for aortic valve was 0.872–0.940), and ICC estimate for pulmonary hypertension was 0.929–0.967. Good reliability has been found for the assessment of volume status with inferior vena cava diameter (ICC estimate for assessing hypovolemia was 0.790–0.902).Conclusion:Intensivists with requisite training in TTE were able to perform focused echocardiography with comparable accuracy to that of cardiologists. Further studies are required to elucidate the therapeutic implications of fTTE performed by the intensivists.

Rationale and Description of Right Ventricle-Protective Ventilation in ARDS.

Pulmonary vascular dysfunction is associated with ARDS and leads to increased right-ventricular afterload and eventually right-ventricular failure, also called acute cor pulmonale. Interest in acute cor pulmonale and its negative impact on outcome in patients with ARDS has grown in recent years. Right-ventricular function in these patients should be closely monitored, and this is helped by the widespread use of echocardiography in intensive care units. Because mechanical ventilation may worsen right-ventricular failure, the interaction between the lungs and the right ventricle appears to be a key factor in the ventilation strategy. In this review, a rationale for a right ventricle-protective ventilation approach is provided, and such a strategy is described, including the reduction of lung stress (ie, the limitation of plateau pressure and driving pressure), the reduction of PaCO2 , and the improvement of oxygenation. Prone positioning seems to be a crucial part of this strategy by protecting both the lungs and the right ventricle, resulting in increased survival of patients with ARDS. Further studies are required to validate the positive impact on prognosis of right ventricle-protective mechanical ventilation.

Feasibility of focused transthoracic echocardiography in intensive care unit performed by intensivists

To assess the clinical applicability of focused transthoracic echocardiography (TTE) in intensive care unit (ICU) performed by intensivists and its impacts on clinical managements. After 12-hour tutorials and initial cardiac clinical assessments, intensivists performed a focused TTE (2-4 views of 2D, without Doppler or M mode) examination in 88 patients to assess left ventricular function and left ventricular volume status, and rule out local ventricular wall motion abnormalities and significant pericardial effusions. Each investigation was immediately reviewed by an echocardiograph to determine the technical quality of the TTE and the accuracy of the intensivist's interpretation. Intensivists successfully performed a diagnostic focused TTE in 86 patients (97.7%) and interpreted correctly in 75 patients (85.2%). Management including fluid treatment, inotropic agent and vasoactive agent in 22.7% of patients were changed directly based on the focused TTE, 45.5% of patients were provided with valuable information, while 31.8% of them with non-valuable information. The mean focused TTE acquisition time of the intensivist was (11.2±5.2) minutes. After a brief standard training in using echocardiographic system, intensivists can successfully performed and correctly interpreted a focused TTE for critically ill patients. Our study demonstrates that new information can be provided by focused TTE, which can alter management in a significant number of patients. The present study supports incorporating bedside goal-directed, focused TTE into intensivists' training programs in China.

Takotsubo cardiomyopathy resembling acute high lateral myocardial infarction

A 65-year-old female patient admitted to the emergency department was diagnosed with acute high lateral myocardial infarction, but later Takotsubo cardiomyopathy (TC) was discovered. She had squeezing chest pain that started shortly after an emotional stress. The electrocardiogram revealed a loss of R wave voltage in leads V1 to V4 and an ST-segment elevation in I and aVL. After an urgent coronary angiography and ventriculography, TC was considered, and supportive anti-ischemic treatment was started. The severe left ventricular systolic dysfunction improved and normalized during the follow-up. She was discharged without any complications. TC is a new entity of acute cardiac events, and patients usually recover completely without sequelae with proper diagnosis and management. An exact diagnosis may also prevent an inappropriate application in the setting of recurrences.

Role of echocardiography in the hemodynamic monitorization of critical patients

The use of echocardiography in intensive care units in shock patients allows us to measure various hemodynamic variables in an accurate and non-invasive manner.By using echocardiography not only as a diagnostic technique but also as a tool for continuous hemodynamic monitorization, the intensivist can evaluate various aspects of shock states, such as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures, heart–lung interaction and biventricular interdependence.However, to date there has been little guidance orienting echocardiographic hemodynamic parameters in the intensive care unit, and intensivists are usually not familiar with this tool.In this review, we describe some of the most important hemodynamic parameters that can be obtained at the patient bedside with transthoracic echocardiography in critically ill patients.

Papel de la ecocardiografía en la monitorización hemodinámica de los pacientes críticos

The use of echocardiography in intensive care units in shock patients allows us to measure various hemodynamic variables in an accurate and a non-invasive manner.By using echocardiography not only as a diagnostic technique but also as a tool for continuous hemodynamic monitorization, the intensivist can evaluate various aspects of shock states, such as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures, heart-lung interaction and biventricular interdependence.However, to date there has been little guidance orienting echocardiographic hemodynamic parameters in the intensive care unit, and intensivists are usually not familiar with this tool.In this review, we describe some of the most important hemodynamic parameters that can be obtained at the patient bedside with transthoracic echocardiography in critically ill patients.

Ecocardiografia à beira do leito em terapia intensiva: uma realidade ou um sonho distante?

During the last few years, technological development and acquired experience advanced and the echocardiogram has become an important and useful tool in intensive care unit environment. Data obtained from semi quantitative Doppler echocardiography (transthoracic and transesophageal) evaluation has contributed to an appropriate patient monitoring and management. Echocardiography as a diagnostic, prognostic and monitoring method for fluid responsiveness assessment has become available nowadays since hand-carried ultrasound devices are portable and cheaper. Adequate training and development of appropriateness criteria for use of echocardiography in intensive care unit may lead to a standard use as a bedside tool.

Echocardiography in the intensive care unit: from evolution to revolution?

Over recent decades, echocardiography has become a pivotal diagnostic tool for the assessment of patients with hemodynamic compromise in general intensive care units (ICUs). In addition to its imaging capability, echocardiography provides a detailed cardiovascular assessment, based on the combination of real-time two-dimensional evaluation of cardiac structure and function and hemodynamic information provided by Doppler measurement of blood flow velocity. However, despite its ease of use, portability and accuracy, the diffusion of echocardiography among ICUs has been limited by various factors. We discuss here the main reasons for the slow acceptance by the critical care community of echocardiography as a first-line diagnostic tool for the evaluation of hemodynamically unstable patients. One of these reasons is probably the absence, in most countries, of a training program in echocardiography specifically dedicated to intensivists. We report recent French experience in the organization of specific echocardiographic certification aimed at intensivists and anesthesiologists. We strongly believe that a broader use of echocardiography would be beneficial in terms of diagnostic capability and patient management. Therefore, we would like to involve colleagues from other countries and the European Society of Intensive Care Medicine in defining the objectives of echocardiography training for intensivists and in organizing postgraduate courses and training programs aimed at developing the use of echocardiography in ICUs. This would allow the current "evolution" in mentalities to become a true "revolution" in our daily practice.

Frequency of bacteremia associated with transesophageal echocardiography in intensive care unit patients

To determine the occurrence rate of bacteremia associated with transesophageal echocardiography in intensive care unit (ICU) patients. A prospective study of 139 patients undergoing transesophageal echocardiography. The medical ICU of a tertiary referral teaching hospital. One hundred thirty-nine ICU patients (mean age 58 yrs) who underwent transesophageal echocardiography. Blood samples were systematically drawn for aerobic and anaerobic culture at the following times: before (blood culture 1), at the end of (blood culture 2), and 30 mins after (blood culture 3) transesophageal echocardiography examinations. The mean duration of transesophageal echocardiography was 35 mins (range 7 to 120). One hundred thirty-four patients received mechanical ventilation; 125 patients had a nasogastric tube. Fifty-one patients had one or more underlying conditions that usually justify antimicrobial prophylaxis of bacterial endocarditis before high-risk procedures. Fifty-six patients did not receive any antibiotic treatment at the time of transesophageal echocardiography. In 114 patients, the three blood cultures were negative. In six patients, transesophageal echocardiography was performed during a preexisting bacteremia. A contamination (only one positive blood culture of the three sampling times) with coagulase-negative staphylococci occurred in four patients at blood culture 1, five patients at blood culture 2, and six patients at blood culture 3. Contamination with Corynebacterium species occurred in two patients at blood culture 2. In one patient receiving cefotaxime and netilmicin, blood culture 1 was sterile and blood cultures 2 and 3 yielded coagulase-negative staphylococci. In one patient receiving no antibiotic treatment, blood culture 1 was sterile and blood cultures 2 and 3 yielded Enterococcus faecalis. None of these two patients received a specific antibiotic treatment or developed any secondary septic focus. The overall frequency of bacteremia induced by transesophageal echocardiography in ICU patients was 1.4% (two of 139 patients) (95% confidence interval 0.2% to 5.1%). The frequency did not differ whether patients received antibiotics before transesophageal echocardiography (one [1.2%] of 83 patients) or not (one [1.8%] of 56 patients) (p = .96). Therefore, routine antimicrobial prophylaxis does not appear justified before transesophageal echocardiography in ICU patients.