ICS State of the Art Meeting 2015

1. Intensivist-delivered echo:
dangerous in the wrong
hands?
Susanna Price
Cardiologist & Intensivist
Royal Brompton Hospital

2. cardiologist vs intensivist?

3. Intensivist-delivered echo:
dangerous in the wrong
hands?
Susanna Price
Cardiologist & Intensivist
Royal Brompton Hospital

4. What is this discussion really about?

5. Repeated studies, out of hours, timely manner
Training and education – echo and intensive care?
Lack of availability of cardiologists?

6. focused cardiac ultrasound vs comprehensive echo
High-end vs miniaturised machine
Limited/full range of advanced techniques?
Different “weapons”

7. Time required for the study?

8. What if something is missed/misinterpreted?

9. Inappropriate discrediting of the technique?

10. inability to compromise on point of principle?
Ownership?

11. The very best: for optimal patient care and safety
What this discussion is really about….

12. 1971: first real-time 2D scanner
1983: 3D echocardiography
1988: intravascular ultrasound

13. ©FEEL-UK
b. Physiologya. Monitoring
c. Perfusion
Pitfalls
Echocardiography in the critically ill?
d. Anatomy

14. ER, ICU, anaesthesia
Penetrating trauma, blunt trauma
Postcardiotomy due to cardiac surgery
Hypotension, shock of unknown origin
Unconsciousness, unresponsiveness
Acute severe dyspnoea
Syncope in young adults
Vein thrombosis
Acute myocardial infarction (AMI)), mechanical complications of AMI
Atypical chest pain: suspected aortic dissection, suspected aortic abdominal or
thoracic aneurysm, nontraumatic cardiac rupture
Iatrogenic complications because of invasive procedures (e.g. Insertion of an
artificial pacemaker, pulmonary artery catheter, electrophysiologic
investigative procedures)
Great vessel disease
Cardiac Arrest:
Pulseless electrical activity
Suspected cardiac tamponade
Early detection of ROSC
Bradycardia-asystole, pacemaker-ECG
Performance of CPR
Effectiveness of chest compressions
Hypotension, adaptation of vasopressors
ICU
Systolic function and regional wall motion abnormalities
Diastolic function
Hypovolemia and volume responsiveness
Tamponade and pericardial disease
The sepsis syndromes
Effects of pre-load and afterload and assessment of filling status
Acute cor pulmonale
Hypoxemia
Complications of acute MI
Chest trauma
Assessment of shock
Failure to wean from mechanical ventilation
Hemodynamic measurements
Anaesthesia
Cardiac surgery
Intraoperative TOE and epicardial echocardiography
Postoperative assessment on the ICU (TOE and TTE)
surgery-specific
general
Non-cardiac surgery
Intraoperative high-risk cases
Systolic function and regional wall motion abnormalities
Hypovolemia and volume responsiveness
Effects of pre-load and afterload and assessment of filling status
Hemodynamic measurements
Potential scope of critical echocardiography

15. Evidence-base?: PubMed
Echocardiography
Critical Care echo

16. Setting the scene…

17. Setting the scene…
Patient-centred care – critical care without walls
Environment frequently suboptimal

20. ABGs

22. Who do you want?
• Most experienced, skilled and expert

24. Of the 36 ways of
avoiding disaster in ICU
echo, running away is
the best …
Reality?

30. ALL RIGHT: BUT APART FROM
THE SANITATION
THE MEDICINE
EDUCATION
WINE
PUBLIC ORDER
IRRIGATION
ROADS
THE FRESH-WATER SYSTEM
AND PUBLIC HEALTH
WHAT HAVE THE ROMANS EVER DONE FOR US?

32. What do the cardiologists say?
“The real benefit to the patient [of echocardiography] is not the technical skill, but rather
the application of intellectual input…. information, communication and teamwork are
essential (Jos Roelandt, 1993)”
“from an ethical point of view, emergency echo should be
performed by anyone who is adequately trained….
with the necessary knowledge used thoughtfully, correctly and
with care” (EACVI, 2014)
“ It is strongly recommended that all cardiologists….complete an additional training
programme consisting in interpreting/reporting….echocardiographic examinations in
critical or life-saving scenarios, in order to further improve technical skills and build
experience….For non-cardiologists the requirements are essentially the same” (ESC
EACVI/ACCA, 2015)
Lancellotti P, Price S, Edvardsen T et al.,
Eur Heart J Cardiovasc Imaging. 2015 Feb;16(2):119-46

33. Different viewpoints – same situation – coming together?

35. Intensivist-delivered echo:
dangerous in the wrong
hands?
Susanna Price
Cardiologist & Intensivist
Royal Brompton Hospital

38. Intensive care echo:
dangerous in the wrong
hands
Susanna Price
Cardiologist & Intensivist
Royal Brompton Hospital

39. ..that one day all critically ill patients who might benefit
from the intelligent application and interpretation of
echocardiography will do so…