Goal-directed Echocardiography Research Articles

Lung ultrasound for the sick child: less harm and more information than a radiograph.

In the realm of emergency medicine, the swift adoption of lung ultrasound (LU) has extended from the adult population to encompass pediatric and neonatal intensivists. LU stands out as a bedside, replicable, and cost-effective modality, distinct in its avoidance of ionizing radiations, a departure from conventional chest radiography. Recent years have witnessed a seamless adaptation of experiences gained in the adult setting to the neonatal and pediatric contexts, underscoring the versatility of bedside Point of care ultrasound (POCUS). This adaptability has proven reliable in diagnosing common pathologies and executing therapeutic interventions, including chest drainage, and central and peripheral vascular cannulation. The surge in POCUS utilization among neonatologists and pediatric intensivists is notable, spanning economically advanced Western nations with sophisticated, high-cost intensive care facilities and extending to low-income countries. Within the neonatal and pediatric population, POCUS has become integral for diagnosing and monitoring respiratory infections and chronic and acute lung pathologies. This, in turn, contributes to a reduction in radiation exposure during critical periods of growth, thereby mitigating oncological risks. Collaboration among various national and international societies has led to the formulation of guidelines addressing both the clinical application and regulatory aspects of operator training. Nevertheless, unified guidelines specific to the pediatric and neonatal population remain lacking, in contrast to the well-established protocols for adults. The initial application of POCUS in neonatal and pediatric settings centered on goal-directed echocardiography. Pivotal developments include expert statements in 2011, the UK consensus statement on echocardiography by neonatologists, and European training recommendations. The Australian Clinician Performed Ultrasound (CPU) program has played a crucial role, providing a robust academic curriculum tailored for training neonatologists in cerebral and cardiac assessment. Notably, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) recently disseminated evidence-based guidelines through an international panel, delineating the use and applications of POCUS in the pediatric setting. These guidelines are pertinent to any professional tending to critically ill children in routine or emergency scenarios. In light of the burgeoning literature, this paper will succinctly elucidate the methodology of performing an LU scan and underscore its primary indications in the neonatal and pediatric patient cohort. The focal points of this review comprise as follows: (1) methodology for conducting a lung ultrasound scan, (2) key ultrasonographic features characterizing a healthy lung, and (3) the functional approach: Lung Ultrasound Score in the child and the neonate. Conclusion:the aim of this review is to discuss the following key points: 1. How to perform a lung ultrasound scan 2. Main ultrasonographic features of the healthy lung 3. The functional approach: Lung Ultrasound Score in the child and the neonate What is Known: • Lung Ultrasound (LUS) is applied in pediatric and neonatal age for the diagnosis of pneumothorax, consolidation, and pleural effusion. • Recently, LUS has been introduced into clinical practice as a bedside diagnostic method for monitoring surfactant use in NARDS and lung recruitment in PARDS. What is New: • Lung Ultrasound (LUS) has proven to be useful in confirming diagnoses of pneumothorax, consolidation, and pleural effusion. • Furthermore, it has demonstrated effectiveness in monitoring the response to surfactant therapy in neonates, in staging the severity of bronchiolitis, and in PARDS.

269 Added Prognostic Value of Right Ventricular Dysfunction Assessments

To determine if the addition of abnormal right ventricle (aRV) variables add prediction accuracy for 5- and 30-day clinical deterioration (CD) in patients classified as low-risk by the simplified Pulmonary Embolism Severity Index (sPESI). Our secondary objective was to determine the variable prognostic importance of right ventricle (RV) assessments. We performed a planned analysis of low-risk sPESI patients derived from a prospective, multi-center, registry. RV assessments included goal-directed echocardiography (GDE), computed tomography (CT), natriuretic peptide and troponin. We developed and compared machine learning (random forest [RF]) prediction models; full (with RV variables) and reduced (without RV variables) for the primary and secondary outcomes. For statistical inference, we used variable importance plots from the full RF model and logistic regression derived log odds. Of 1736 patients, 611 (35.2%) were “low-risk” by sPESI. Of the 611, 75 (12.3%) experienced CD within five days. Proportions of low-risk sPESI with aRV criteria by CT, GDE, troponin, and natriuretic peptide were 26.2%, 20.6% 17.7% and 23.1% respectively. For the primary outcome, full and reduced prediction model AUCs were 0.80 (95% CI 0.77, 0.82) and 0.71 (95% CI 0.68, 0.73) respectively. RV assessments were the top four in the variable importance plot. GDE and CT added significant increases to predicted probability. aRV findings are common amongst those deemed low-risk by sPESI, and one in ten may experience CD within five days. Similarly, one in five may suffer CD within 30 days. The addition of RV assessments improved prognostic value over the reduced model in sPESI patients; GDE was most important in predicting CD.

CORRELATION OF CARDIAC OUTPUT MEASUREMENT BY GOAL-DIRECTED ECHOCARDIOGRAPHY PERFORMED BY INTENSIVISTS VS PULMONARY ARTERY CATHETER

SESSION TITLE: Advances in Critical Care Practice SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Measurement of cardiac output (CO) is often performed in the assessment of critically ill patients with undifferentiated shock. Doppler echocardiography has been shown to be a reliable method for estimating cardiac output when images are acquired by cardiac sonographers and interpreted by cardiologists. However, few studies have assessed the accuracy of CO measurements by Doppler echocardiography performed by non-cardiac intensivists. The purpose of this study was to compare the accuracy of CO measurements by Doppler echocardiography performed by non-cardiac intensivists vs. measurements by pulmonary artery catheter (PAC). METHODS: A prospective observational study of critically ill patients with a PAC in place was conducted. Patients in sinus rhythm and without severe mitral or aortic regurgitation were included. Two non-cardiac intensivists who were not caring for the patients and were blinded to the patients’ clinical and hemodynamic data performed transthoracic goal-directed echocardiograms on all subjects. Stroke volume (SV) was calculated using a 3-beat average of the Left Ventricular Outflow Tract (LVOT) Velocity Time Integral measured by pulsed-wave Doppler and the 2-dimensional diameter of the LVOT, and CO was calculated by multiplying SV by heart rate. Simultaneously, ICU-trained nurses obtained 3 different PAC-CO measurements by thermodilution, which were subsequently averaged. Association analysis was performed using linear regression and Pearson correlation. RESULTS: Eighty-six simultaneous PAC-CO and Echo-CO measurements were obtained in 32 consecutive patients. The patients’ mean age was 66 years and most common comorbidities included acute coronary syndrome (50%), respiratory failure on mechanical ventilation (37%), and post-cardiac surgery (87%). Most patients (56%) had a left ventricular ejection fraction (LVEF) <40%, and the average LVEF was 31%. A strong correlation between Echo-CO and PAC-CO was seen (Pearson correlation R=0.89; p<0.001). The linear regression coefficient was 1.09 (95%CI 0.97-1.21; p<0.001) with an R2 of 0.79, suggesting a strong linear correlation. Both mechanically ventilated patients (n=50) and those breathing spontaneously (n=36) had a strong Echo-CO to PAC-CO correlation (R=0.83 and 0.92, respectively; p<0.001 for both subgroups). CONCLUSIONS: Cardiac output measured by non-cardiac intensivists using goal-directed echocardiography had a strong correlation with gold standard measurements by thermodilution using a pulmonary artery catheter. CLINICAL IMPLICATIONS: Noninvasive measurement of cardiac output in critically ill patients using Doppler echocardiography is an accurate technique when performed by non-cardiac intensivists. DISCLOSURES: No relevant relationships by Edgar Ballesteros, source=Web Response No relevant relationships by Jairo Gonzalez Quintero, source=Web Response No relevant relationships by Arnold Mendez-Toro, source=Web Response No relevant relationships by Gabriel Ortiz Jaimes, source=Web Response No relevant relationships by Nilam Soni, source=Web Response

IMPORTANCE OF POINT-OF-CARE ULTRASONOGRAPHY IN THE EVALUATION OF UNDIFFERENTIATED SHOCK

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute pulmonary embolism (PE) affects at least one in every 1000 individuals. Diagnosing PE accurately and in a timely manner can be challenging as the clinical presentation of PE is variable. In fact, up to two-thirds of clinically significant PE are undiagnosed until autopsy. Point-of-care ultrasonography (POCUS) has developed into a vital tool that can assist clinicians in appropriately diagnosing PE and elucidating etiology of undifferentiated shock. CASE PRESENTATION: A 71-year-old female with a history of reactive airway disease and minimal change nephropathy presented with two days of progressive dyspnea and wheezing. Vital signs on arrival were notable for tachycardia of 180 beats per minutes, hypotension of 86/50, and hypoxia which required four liters of supplemental oxygen to correct. Electrocardiogram showed new-onset atrial fibrillation (AF) with rapid ventricular response. Laboratory analysis was remarkable for a neutrophil predominant leukocytosis of 18.2 x 10^3/mcL, a serum bicarbonate of 14 mmol/L, blood urea nitrogen 36 mg/dL, creatinine 2.2 mg/dL, and a lactic acid greater than 12 mmol/L. A chest radiograph revealed no significant parenchymal infiltrates (Figure 1). Her condition quickly deteriorated requiring escalating doses of vasopressors and ventilatory support. POCUS cardiac exam identified right ventricular (RV) dilatation and McConnell’s sign (RV free wall hypokinesis with hyperdynamic apex) (Figure 2A-B). Furthermore, ultrasound evaluation of her lower extremities confirmed the presence of multiple deep vein thrombi. Given the high suspicion for massive PE, systemic intravenous tissue plasminogen activator was administered. Subsequently, hemodynamics started improving with a rapid decrease in vasopressor requirements. Unfortunately, the hospital course was complicated by acute renal failure prompting transition to comfort care measure per the patient’s wishes rather than pursing hemodialysis. DISCUSSION: Shock can be categorized into cardiogenic, hypovolemic, distributive/vasoplegic, and obstructive. Obstructive shock is caused by resistance to blood flow through the circulatory system. This can result from PE, cardiac tamponade, or pneumothorax. POCUS has been validated as a reliable tool to identify obstructive shock. Hallmark findings on POCUS for PE include, RV dilatation, septal flattening, paradoxical septal wall motion, and McConell’s sign. Additionally, the presence of new-onset AF in undifferentiated shock should prompt evaluation for PE, as those diagnosed with PE who present with AF have an increased mortality. CONCLUSIONS: Obstructive shock secondary to PE should always be considered in cases of undifferentiated shock. Moreover, all clinicians should become familiar with the role of POCUS in the evaluation of undifferentiated shock, as it can oftentimes provide rapid, reliable, and clinically actionable information. Reference #1: McLean A. S. (2016). Echocardiography in shock management. Critical care (London, England), 20, 275. https://doi.org/10.1186/s13054-016-1401-7 Reference #2: Walley, P. E., Walley, K. R., Goodgame, B., Punjabi, V., & Sirounis, D. (2014). A practical approach to goal-directed echocardiography in the critical care setting. Critical care (London, England), 18(6), 681. https://doi.org/10.1186/s13054-014-0681-z Reference #3: Matthews, J. C., & McLaughlin, V. (2008). Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Current cardiology reviews, 4(1), 49–59. https://doi.org/10.2174/157340308783565384 DISCLOSURES: No relevant relationships by Ethan Karle, source=Web Response No relevant relationships by Armin Krvavac, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by Rodger Wilhite, source=Web Response

Diagnostic Accuracy of Point-of-Care Ultrasound Performed by Pulmonary Critical Care Physicians for Right Ventricle Assessment in Patients With Acute Pulmonary Embolism.

Risk stratification for acute pulmonary embolism using imaging presence of right ventricular dysfunction is essential for triage; however, comprehensive transthoracic echocardiography has limited availability. We assessed the accuracy and timeliness of Pulmonary Critical Care Medicine Fellow's performance of goal-directed echocardiograms and intensivists' interpretations for evaluating right ventricular dysfunction in acute pulmonary embolism. Prospective observational study and retrospective chart review. Four hundred fifty bed urban teaching hospital. Adult in/outpatients diagnosed with acute pulmonary embolism. Pulmonary critical care fellows performed and documented their goal-directed echocardiogram as normal or abnormal for right ventricular size and function in patients with acute pulmonary embolism. Gold standard transthoracic echocardiography was performed on schedule unless the goal-directed echocardiogram showed critical findings. Attending intensivists blinded to the clinical scenario reviewed these exams at a later date. Two hundred eighty-seven consecutive patients were evaluated for acute PE. Pulmonary Critical Care Medicine Fellows performed 154 goal-directed echocardiograms, 110 with complete cardiology-reviewed transthoracic echocardiography within 48 hours for comparison. Pulmonary Critical Care Medicine Fellow's area under the curve for size and function was 0.83 (95% CI, 0.75-0.90) and 0.83 (95% CI, 0.75-0.90), respectively. Intensivists' 1/2 area under the curve for size and function was (1) 0.87 (95% CI, 0.82-0.94), (1) 0.87 (95% CI, 0.80-0.93) and (2) 0.88 (95% CI, 0.82-0.95), (2) 0.88 (95% CI, 0.82-0.95). Median time difference between goal-directed echocardiogram and transthoracic echocardiography was 21 hours 18 minutes. This is the first study to evaluate pulmonary critical care fellows' and intensivists' use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism.

Utility of Point-of-Care Ultrasound for In-Hospital Cardiac Arrest

SESSION TITLE: Rapid Session: Bedside Imaging SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 07:30 AM - 08:30 AM PURPOSE: The objective in management of patients experiencing cardiac arrest is to identify reversible causes. The introduction of Point-of-Care Ultrasound (POCUS) into critical care has opened avenues not previously available in the management of these patients. We aimed to observe the effects of introduction of POCUS in management of patients experiencing in-hospital cardiac arrest (IHCA). IHCA has been reported to have a survival rate of 6.6% to hospital discharge. While multiple protocols exist for intra-arrest echocardiography, a recent meta-analysis of 15 studies examining POCUS in cardiac arrest consisted entirely of pre-hospital and/or Emergency Department settings. This is the first study examining the impact of POCUS on IHCA. METHODS: We collected a convenience sample of 19 patients with IHCA between July 2016 and February 2017 who had a POCUS performed as part of their management due to critical care fellow availability. In our tertiary-care urban community teaching hospital, we have ultrasound-trained critical care fellows and faculty. In general, we would perform POCUS in cases where a second fellow would be available to perform and interpret the exam since the primary fellow would be involved with other aspects of patient care during cardiac arrest. RESULTS: Out of 75 total IHCA at our institution during the study period, 24 occurred during times when 2 fellows would normally be present and were announced overhead. 15 of our studies occurred during this time period (4 occurred outside of this time period), yielding 63% of potential IHCA patients underwent POCUS. Average age of patients was 67.7 years and 52.6% of them were male. 47.4% of arrests occurred in the medical ICU and PEA was the initial rhythm in 73.7% of patients. Average time of CPR was 16.1 minutes (Range 4-37) and 73.7% of patients achieved ROSC. All patients had goal-directed echocardiography including, at minimum, a subcostal view. 5.3% of patients (1/19) received tPA due to severe RV dysfunction. One patient had a small IVC diameter and therefore received IV Fluids. All patients who were checked for lung sliding had lung sliding present and therefore pneumothorax was ruled out as a cause of cardiac arrest. No pericardial effusions were noted and therefore cardiac tamponade was ruled out as a cause of cardiac arrest. LV function was found to be normal or hyperdynamic in 6 patients, all of whom achieved ROSC. CONCLUSIONS: POCUS is feasible and useful in management of patients experiencing in-hospital cardiac arrest. CLINICAL IMPLICATIONS: POCUS should play a larger role for IHCA in hospitals which have that capability. Future studies should focus on larger patient population and potential use of POCUS in assessing efficacy of compressions by examining real-time surrogate markers of stroke volume. DISCLOSURE: The following authors have nothing to disclose: Eric Bondarsky, Lina Miyakawa, Angela Love, Paru Patrawalla, Samuel Acquah, Young Im Lee No Product/Research Disclosure Information

Assessment of Left Ventricular Function in the Critically Ill Patient

A rapid qualitative assessment of left ventricular (LV) function is one of the cornerstones of point of care ultrasonography. The purpose of this review is to use a case-based approach to demonstrate how point of care echocardiography can be used to perform a qualitative assessment of LV systolic function. Various studies have demonstrated that using standard goal-directed echocardiography views, the assessment of myocardial thickening, endocardial excursion and the motion of the anterior leaflet of the mitral valve can be used to classify the LV systolic function into four broad categories: (1) normal, (2) hyperdynamic, (3) reduced, and (4) severely reduced LV function. Rapid qualitative assessment of LV systolic function provides valuable information, especially in patients with undifferentiated shock. However, it is important for the sonographer to recognize their limitations, be well versed in the pitfalls of each technique, and request a formal evaluation where appropriate.

Prognostic Value of Right Ventricular Dysfunction Markers for Serious Adverse Events in Acute Normotensive Pulmonary Embolism

BackgroundRight ventricular dysfunction (RVD) in pulmonary embolism (PE) has been associated with increased morbidity. Tools for RVD identification are not well defined. The prognostic value of RVD markers to predict serious adverse events (SAE) during hospitalization is unclear. ObjectiveProspectively compare the incidence of SAE in normotensive emergency department patients with PE based upon RVD by goal-directed echocardiography (GDE), cardiac biomarkers, and right-to-left ventricle ratio by computed tomography (CT). Simplified Pulmonary Embolism Severity Index (sPESI) was calculated. Deaths and readmissions within 30 days were recorded. MethodsConsecutive normotensive PE patients underwent GDE focused on RVD (RV enlargement, hypokinesis, or septal bowing), serum troponin, and brain natriuretic peptide (BNP), and evaluation of the CT ventricle ratio. In-hospital SAE and complications within 30 days were recorded. ResultsWe enrolled 123 normotensive PE patients (median age 59 years, 49% female). Twenty-six of 123 (26%) patients had one or more SAE. RVD was detected in 26% by GDE, in 39% by biomarkers, and in 38% with CT. In-hospital SAE included one death, six respiratory interventions, six dysrhythmias, three major bleeding episodes, and 21 hypotension episodes. Forty-one percent of patients RVD positive by GDE had SAE, compared to the 18% RVD negative by GDE. Odds ratios for GDE, CT, BNP, troponin, and sPESI for SAE were 3.2 (95% confidence interval [CI] 1.2–8.5), 2.0 (95% CI 0.8–5.1), 3.3 (95% CI 1.3–8.6), 4.2 (95% CI 1.4–13.5), and 2.9 (95% CI 1.1–8.3), respectively. Five patients had non-PE-related deaths within 30 days. ConclusionThe incidence of SAE within days of PE was significant in our cohort. Those with RVD had an increased risk of nonmortality SAE.

Effectiveness of a Critical Care Ultrasonography Course

Widespread use of critical care ultrasonography (CCUS) for the management of patients in the ICU requires an effective training program. The effectiveness of national and regional CCUS training courses is not known. This study describes a national-level, simulation-based, 3-day CCUS training program and evaluates its effectiveness. Five consecutive CCUS courses, with a total of 363 people, were studied. The 3-day CCUS training program consisted of didactic lectures, ultrasonography interpretation sessions, and hands-on modules with live models. Thoracic, vascular, and abdominal ultrasonography were taught in addition to goal-directed echocardiography. Learners rotated between hands-on training and interpretation sessions. The teacher-to-learner ratio was 1:3 during hands-on training. Interpretation sessions were composed of interactive small groups that reviewed normal and abnormal ultrasonography images. Learners completed a video-based examination before and after completion of the courses. Hands-on image acquisition skills were tested at the completion of the course. Average scores on the pretest and posttest were 57%and 90%, respectively (P<.001). The average score on the hands-on test was 86%. Learners aged 20 to 39 years compared with learners≥ 40 years old scored better on the pretest (64%vs51%; P< 0.001), posttest (91%vs88%; P< .010), and hands-on test (90%vs82%; P< .001). Learners demonstrated a significant improvement in written test scores that assessed cognitive and image interpretation abilities. In addition, they demonstrated acquisition of practical skills as evidenced by high scores during hands-on testing. Further studies are needed to determine if a simulation-based CCUS course will translate into effective clinical practice and to measure the durability of training. This 3-day course is an effective method to train large groups of critical care clinicians in the skills requisite for CCUS (image acquisition and image interpretation).

Ultrasonography in the emergency department.

Point-of-care ultrasonography (POCUS) is a useful imaging technique for the emergency medicine (EM) physician. Because of its growing use in EM, this article will summarize the historical development, the scope of practice, and some evidence supporting the current applications of POCUS in the adult emergency department. Bedside ultrasonography in the emergency department shares clinical applications with critical care ultrasonography, including goal-directed echocardiography, echocardiography during cardiac arrest, thoracic ultrasonography, evaluation for deep vein thrombosis and pulmonary embolism, screening abdominal ultrasonography, ultrasonography in trauma, and guidance of procedures with ultrasonography. Some applications of POCUS unique to the emergency department include abdominal ultrasonography of the right upper quadrant and appendix, obstetric, testicular, soft tissue/musculoskeletal, and ocular ultrasonography. Ultrasonography has become an integral part of EM over the past two decades, and it is an important skill which positively influences patient outcomes.

Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients With Acute Pulmonary Embolism

We determine the diagnostic accuracy of goal-directed echocardiography, cardiac biomarkers, and computed tomography (CT) in early identification of severe right ventricular dysfunction in normotensive emergency department patients with pulmonary embolism compared with comprehensive echocardiography. This was a prospective observational study of consecutive normotensive patients with confirmed pulmonary embolism. Investigators, blinded to clot burden and biomarkers, performed qualitative goal-directed echocardiography for right ventricular dysfunction: right ventricular enlargement (diameter greater than or equal to that of the left ventricle), severe right ventricular systolic dysfunction, and septal bowing. Brain natriuretic peptide and troponin cutoffs of greater than or equal to 90 pg/mL and greater than or equal to 0.07 ng/mL and CT right ventricular:left ventricular diameter ratio greater than or equal to 1.0 were also compared with comprehensive echocardiography. One hundred sixteen normotensive pulmonary embolism patients (111 confirmed by CT, 5 by ventilation-perfusion scan) were enrolled. Twenty-six of 116 patients (22%) had right ventricular dysfunction on comprehensive echocardiography. Goal-directed echocardiography had a sensitivity of 100% (95% confidence interval [CI] 87% to 100%), specificity of 99% (95% CI 94% to 100%), positive likelihood ratio (+LR) of 90.0 (95% CI 16.3 to 499.8), and negative likelihood ratio (-LR) of 0 (95% CI 0 to 0.13). Brain natriuretic peptide had a sensitivity of 88% (95% CI 70% to 98%), specificity of 68% (95% CI 57% to 78%),+LR of 2.8 (95% CI 2.0 to 3.9), and -LR of 0.17 (95% CI 0.06 to 0.43). Troponin had a sensitivity of 62% (95% CI 41% to 80%), specificity of 93% (95% CI 86% to 98%),+LR of 9.2 (95% CI 4.1 to 20.9), and -LR of 0.41 (95% CI 0.24 to 0.62). CT had a sensitivity of 91% (95% CI 72% to 99%), specificity of 79% (95% CI 69% to 87%),+LR of 4.3 (95% CI 2.8 to 6.7), and -LR of 0.11 (95% CI 0.03 to 0.34). Goal-directed echocardiography was highly accurate for early severe right ventricular dysfunction identification and pulmonary embolism risk-stratification. Brain natriuretic peptide was sensitive but less specific, whereas troponin had lower sensitivity but higher specificity. CT had good sensitivity and moderate specificity.

Goal-Directed Transthoracic Echocardiography During Advanced Cardiac Life Support: A Pilot Study Using Simulation to Assess Ability.

Goal-directed echocardiography (GDE) is used to answer specific clinical questions that provide invaluable information to physicians managing a hemodynamically unstable patient. We studied perception and ability of house staff previously trained in GDE to accurately diagnose common causes of cardiac arrest during simulated advanced cardiac life support (ACLS); we compared their results with those of expert echocardiographers. Eleven pulmonary and critical care medicine fellows, 7 emergency medicine residents, and 5 cardiologists board certified in echocardiography were enrolled. Baseline ability to acquire 4 transthoracic echocardiography views was assessed, and participants were exposed to 6 simulated cardiac arrests and were asked to perform a GDE during ACLS. House staff performance was compared with the performance of 5 expert echocardiographers. Average baseline and scenario views by house staff were of good or excellent quality 89% and 83% of the time, respectively. Expert average baseline and scenario views were always of good or excellent quality. House staff and experts made the correct diagnosis in 68% and 77% of cases, respectively. On average, participants required 1.5 pulse checks to make the correct diagnosis. Of house staff, 94% perceived this study as an accurate assessment of ability. In an ACLS-compliant manner, house staff are capable of diagnosing management-altering pathologies the majority of the time, and they reach similar diagnostic conclusions in the same amount of time as expert echocardiographers in a simulated cardiac arrest scenario.

A practical approach to goal-directed echocardiography in the critical care setting.

Urgent cardiac ultrasound examination in the critical care setting is clinically useful. Application of goal-directed echocardiography in this setting is quite distinct from typical exploratory diagnostic comprehensive echocardiography, because the urgent critical care setting mandates a goal-directed approach. Goal-directed echocardiography most frequently aims to rapidly identify and differentiate the cause(s) of hemodynamic instability and/or the cause(s) of acute respiratory failure. Accordingly, this paper highlights 1) indications, 2) an easily memorized differential diagnostic framework for goal-directed echocardiography, 3) clinical questions that must be asked and answered, 4) practical issues to allow optimal image capture, 5) primary echocardiographic views, 6) key issues addressed in each view, and 7) interpretation of findings within the differential diagnostic framework. The most frequent indications for goal-directed echocardiography include 1) the spectrum of hemodynamic instability, shock, and pulseless electrical activity arrest and 2) acute respiratory failure. The differential diagnostic categories for hemodynamic instability can be remembered using the mnemonic ‘SHOCK’ (for Septic, Hypovolemic, Obstructive, Cardiogenic, and (K) combinations/other kinds of shock). RESP-F (for exacerbation of chronic Respiratory disease, pulmonary Embolism, ST changes associated with cardiac or pericardial disease, Pneumonia, and heart Failure) can be used for acute respiratory failure. The goals of goal-directed echocardiography in the unstable patient are: assessing global ventricular systolic function, identifying marked right ventricular and left ventricular enlargement, assessing intravascular volume, and the presence of a pericardial effusion. In an urgent or emergent setting, it is recommended to go directly to the best view, which is frequently the subcostal or apical view. The five views are the subcostal four-chamber view, subcostal inferior vena cava view, parasternal long axis view, parasternal short axis view, and the apical four chamber view. Always interpret goal-directed echocardiographic findings in the context of clinically available hemodynamic information. When goal-directed echocardiography is insufficient or when additional abnormalities are appreciated, order a comprehensive echocardiogram. Goal-directed echocardiography and comprehensive echocardiography are not to be used in conflict with each other.

Intensive Care Ultrasound: V. Goal-directed Echocardiography

Intensive Care Ultrasound: V. Goal-directed Echocardiography

Shock: Ultrasound to Guide Diagnosis and Therapy

The availability of portable ultrasound devices is changing the approach to the diagnosis and management of shock by offering timely diagnosis and acting to guide therapy. Goal-directed echocardiography (GDE) can be performed well by noncardiologists and consists of a limited number of standard cardiac views: parasternal long axis, parasternal short axis, apical four chamber, subcostal long axis, and inferior vena cava long axis. GDE allows the intensivist to assess left and right ventricular pump function, pericardial effusion, septal dynamics, valvular morphology, major valve failure, and fluid responsiveness. Here, we review the questions involved in a systematic approach to the patient in shock, employing GDE: (1) Is there an imminently life-threatening cause for the shock? (2) Is the shock state likely to be fluid responsive? (3) Is there evidence of pump failure? (4) Is there more than one cause for the shock state? (5) Is the cause of the shock state other than cardiac in origin? In contrast to formal echocardiography, GDE is qualitative, can be performed in a few minutes, is interpreted immediately, can be repeated as often as needed, and is always integrated with other elements of the intensivist's assessment to arrive at an understanding of the basis for the shock and a rational treatment plan. An important part of using GDE is recognizing its limitations and judging when to proceed to a comprehensive echocardiography examination. Competence in GDE has become an essential skill for the practicing intensivist.

Echocardiography by the non-cardiologist: a curriculum for the fast track strategy.

A formal echocardiographic approach in a general intensive care unit requires a 24 hour availability of an expert in echocardiography, who could not be easily found. Therefore, a goal-directed echocardiogram strategy specifically tailored to the intensivist should be created. The concept of goal-directed echocardiography (GDE) has been incompletely evaluated and it is necessary to find a curriculum program to grant proficiency. We propose the Fast-Track Echocardiographic Strategy (FTES) program to accomplish both objectives. All medical associations of echocardiography agree that extensive training and experience are needed to acquire and interpret a formal echocardiogram, however, to answer the five questions of FTES a simpler curriculum program would be enough. The aim of this review study was to propose a curriculum to teach non-cardiologist physicians intensivist (NCPI) to use a GDE such as FTES. A search for published literature, from 1999 until June 2008, in English and French languages in Medline was undertaken in order to find out the most relevant and contemporary studies in this area. Strength of evidence of the articles found was based on five strengths of evidence. A framework for published medical research's critical appraisal and a checklist for sources of bias were used for assessment of studies quality. In overall, all studies showed it was possible to teach NCPI to use a GDE examination. After a critical appraisal of the literature, we proposed FTES program to grant proficiency to NCPI in a GDE, to be used in hemodynamic unstable critically ill patients (hypotension with or without hypoxemia), to answer five simple questions, in order to define an hemodynamic profile and consequently be able to optimize their treatments. In conclusion, probably FTES program should at least be considered.

Utilization of Formal Echocardiography for Shock: The Emperor Has No Clothes

PURPOSE: In the United States, standards for hemodynamic monitoring of patients with shock have changed. The once ubiquitous ‘Swan’ has lost favor thereby leaving only MAP, CVP, lactate and SvO2 measurements readily available. Various devices provide functional hemodynamic monitoring, although, their use remains sporadic secondary to mixed acceptance of the technology and expense. Intensivist-performed, goal-directed echocardiography can evaluate discrete elements of cardiac function, however, widespread use is limited by equipment and training requirements.

Peripartum Cardiomyopathy: An Intensivist's Perspective

Peripartum cardiomyopathy (PPCMP) is a relatively rare form of dilated cardiomyopathy with unknown etiology. A generally accepted definition comprises the following criteria: 1) cardiac failure occurring in the last month of pregnancy or within 5 months after delivery; 2) absence of an alternative cause for the cardiomyopathy; 3) absence of heart disease before the last month of pregnancy and 4) demonstrated left ventricular dysfunction. From an intensivists perspective, the diagnosis of PPCMP should always be considered when triaging a woman with peripartum respiratory or hemodynamic distress. Timely diagnosis is crucial to enable prompt initiation of the proper management in order to minimize the risk for serious maternal and neonatal sequelae. Goal-directed echocardiography should be utilized as early as possible, preferably already in the emergency department, to demonstrate or rule out PPCMP. Only then, appropriate supportive measures such as appropriate medical therapy, intra-aortic balloon counter pulsation (IABP), extracorporeal membrane oxygenation (ECMO) or assist device support can be initiated.

Feasibility and Potential Clinical Utility of Goal-Directed Transthoracic Echocardiography Performed by Noncardiologist Intensivists Using a Small Hand-Carried Device (SonoHeart) in Critically III Patients

Feasibility and Potential Clinical Utility of Goal-Directed Transthoracic Echocardiography Performed by Noncardiologist Intensivists Using a Small Hand-Carried Device (SonoHeart) in Critically III Patients

Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study.

To determine if a focused transthoracic echocardiography (TTE) training course would improve the accuracy of completion and interpretation of a goal-directed TTE by emergency medicine residents. This was a prospective, observational, educational study of the impact of a focused training course on the change in physician performance on pre- and postcourse examinations testing competency in goal-directed TTE defined by five criteria: 1). image orientation, 2). anatomy identification, 3). chamber size grading, 4). ventricular function estimation, and 5). pericardial effusion identification. Subjects included were emergency medicine residents with between ten and 20 hours of noncardiac ultrasound didactics and between 20 and >150 proctored noncardiac ultrasound examinations. All underwent five hours of focused echocardiography didactics and one hour of proctored practical echocardiography training designed and implemented by an emergency physician ultrasound director and a cardiologist. Before the start of the training course, participants completed two examinations: 1) written 23-question test on the above concepts and 2) performance of a TTE on a healthy subject testing 16 elements that define a properly performed examination. After the training course, participants again completed both examinations. A total of 21 emergency medicine residents qualified for and underwent standardized testing and training. The percentage correct on the precourse written examination was 54% (95% CI = 50% to 59%), and the postcourse examination score was 76% (95% CI = 71% to 80%) (p < 0.005, paired t-test). The percentage correct on the precourse practical examination was 56% (95% CI = 51% to 60%), and the postcourse examination score was 94% (95% CI = 91% to 96%) (p < 0.005). A focused six-hour echocardiography training course significantly improved emergency medicine residents' percentage scores on both written and practical examinations testing essential components required for correct goal-directed TTE performance and interpretation.