ECHO by the clinician
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1. Echocardiography provides important information for critically ill patients that can help guide therapy and avoid unnecessary transportation risks. Studies have found that echocardiography can identify new information in 44-48% of ICU patients and lead to changes in therapy. 2. Echocardiography has a wide range of applications in the ICU, ER, and operating room for conditions like shock, cardiac arrest, trauma, acute myocardial infarction, and complications during or after procedures. It can provide data on systolic and diastolic function, volume status, valves, and help guide hemodynamic measurements. 3. Performing echocardiography in the ICU requires understanding the clinical context and what information will be most
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ECHO by the clinician
- 1. Assessment and monitoring: Echocardiography by the clinician Susanna Price MD PhD Consultant Cardiologist & Intensivist Royal Brompton Hospital, NHLI, Imperial College, London, UK
- 2. Conflict of interest? • None
- 3. Why echocardiography in critically ill? • Risks of transportation: AI 8-68% in critically ill • 31% of AIs – significantly adverse outcome, 3% in cardiac arrest • Avoidance of repeated irradiation (staff & patient) • Immediately available, safe
- 4. Critical Echocardiography: a new application? • 44% of patients with a PAC in place have additional information from echo leading to change in therapy (Poelart, Chest 1995) • Aetiology of unexplained hypotension revealed in 48% of MICU patients, leading to change in therapy (Heidenreich 1995) • Focused cardiac ultrasoundimproves diagnostic accuracy and efficiency in the ER (Jones 2004) • Universal definition of AMI includes echocardiography (ESC 2007) • Pre-hospital emergency FoCUS changes therapy in 60-80% (Breitkreutz 2010) • Resuscitation guidelines recommend the use of FoCUS in cardiac arrest (ILCOR 2010)
- 5. 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
- 6. b. Physiologya. Monitoring Pitfalls Echocardiography in the critically ill - scope d. Anatomyc. Perfusion
- 7. Cholley et al., 2006, Price et al., 2008 FoCUS Echo Echocardiography vs FoCUS
- 8. Dr Francisca Caetano – senior echo fellow, RBH
- 9. 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis, EF now normal on inotropic infusion: should we add ivIG or cyclophosphamide or wait? 2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function 4. 42 year-old man post-PCI supported with peripheral VA-ECMO 5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation 7. 45 year old HF arrested and transferred for ongoing therapies 8. 59 year-old, dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO Clinical cases: my ICU one day last week
- 11. Clinical cases: my ICU one day last week 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis 2. 57 year-old post aortic dissection repair – low CO state: does he need MCS, and which? 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function 4. 42 year-old man post-PCI supported with peripheral VA-ECMO 5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation 7. 45 year old HF arrested and transferred for ongoing therapies 8. 59 year-old, dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
- 12. RV tIVT 15, LVtIVT 8, L-VTI 6, PASP 15mmHg, PAT 82msec
- 13. Clinical cases: my ICU one day last week 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis 2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function: is there a right heart component to this and what can I do to resolve? 4. 42 year-old man post-PCI supported with peripheral VA-ECMO 5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation 7. 45 year old HF arrested and transferred for ongoing therapies 8. 59 year-old, dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
- 14. CI 7.8, PASP 52mmHg, CVP +14, milrinone 0.4mcg/kg/min, BiPAP 12+14, FIO2 0.7, saturations 88%
- 15. Clinical cases: my ICU one day last week 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis 2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function 4. 42 year-old man post-PCI supported with peripheral VA-ECMO: are we sure the goals of ECMO are met? 5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation 7. 45 year old HF arrested and transferred for ongoing therapies 8. 59 year-old, dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
- 17. Clinical cases: my ICU one day last week 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis 2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function 4. 42 year-old man post-PCI supported with peripheral VA-ECMO 5. 32 year old transferred from cath lab post pulmonary valvuloplasty: haemorrhage from ETT – why? 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation 7. 45 year old HF arrested and transferred for ongoing therapies 8. 59 year-old, dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
- 19. Clinical cases: my ICU one day last week 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis 2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function 4. 42 year-old man post-PCI supported with peripheral VA-ECMO 5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation: cannula vs beta blockade? 7. 45 year old PH transferred for ongoing therapies 8. 59 year-old, dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
- 21. Clinical cases: my ICU one day last week 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis 2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function 4. 42 year-old man post-PCI supported with peripheral VA-ECMO 5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation 7. 45 year old PH transferred for ongoing therapies, cardiogenic shock: ?options ?improved 8. 59 year-old, dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
- 22. Speaker Pulmonary TAPSE Maximal pulmonary vasodilatation • iNO + Levosimendan + Nebulised prostacyclin + Low dose vasopressin + Nebulised milrinone
- 23. Clinical cases: my ICU one day last week 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis 2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function 4. 42 year-old man post-PCI supported with peripheral VA-ECMO 5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation 7. 45 year old PH arrested and transferred for ongoing therapies 8. 59 year-old dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
- 24. Tei index: [580-200]/200 = 1.9 ET: 0.2x104=20.8sec/min, FT: 0.18x104=18.9 sec/min tIVT: 60-(20.8+18.72) = 20.2 sec/min
- 26. Clinical cases: my ICU one day last week 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis 2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function 4. 42 year-old man post-PCI supported with peripheral VA-ECMO 5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation 7. 45 year old PH transferred for ongoing therapies 8. 59 year-old, dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO
- 28. Clinical cases: my ICU one day last week 1. 38 year old woman, 9 weeks pregnant – resolving cardiogenic shock, SLE, Raynauds, Hashimoto’s thyroiditis 2. 57 year-old post aortic dissection repair – line-related sepsis, GI failure – resolving RV dysfunction 3. 36 year old man, Group A strep – septic shock with multi-organ failure and worsening hepatic function 4. 42 year-old man post-PCI supported with peripheral VA-ECMO 5. 32 year old transferred from cath lab post pulmonary valvuloplasty – haemorrhage from ETT 6. 16 year-old influenza A, VV-ECMO with inadequate oxygenation 7. 45 year old PH transferred for ongoing therapies 8. 59 year-old, dilated cardiomyopathy, arrested post-start of ICD implantation 9. 36 year old peripartum cardiomyopathy – VA-ECMO hoping for recovery 10.18 year-old Influenza B unable to wean off sweep from VV-ECMO: lungs or cannula or heart?
- 32. ABGs
- 34. • What is the clinical context? • What do we really want to know? • What’s the underlying diagnosis? • How is the patient being sedated/ventilated/supported? • What is limiting the cardiac output/elevating the venous pressure? • Is the left atrial pressure elevated? • Is the heart rate/AV delay/VV delay appropriate? • Is there any other relevant information? • Systematic • Reversible? ? can echocardiography answer this? really??? Key questions for the clinician doing echocardiography
- 35. The most important question?
- 36. “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
- 37. • Not “simplified” echocardiography - differentiate from FoCUS • Know the literature – beware injudicious application • Have the full range of echocardiographic techniques available • Determine what the treating clinician needs to be known, not just what you know Don’t be fooled…
- 39. Assessment and monitoring Echo by the clinician Thank you
Editor's Notes
- First – why echo – we have a multitude of imaging techniques…. It is simple,
- ?New application: No publications around 14 years ago suggested that echocardiography gave additional information and revealed the diagnosis in a number of critically ill patients, More recently, evidence has emerged regarding its benefit in the ER, use in the diagnosis of AMI and potential benefit when applied in pre-hospital care Thus, for the CICU patient, its potential use starts early in the pateint pathway, and continues along it
- The potential scope is massive – along the whole patient pathway in acute cardiovascular care – and in particular in intensive care
- Afterload reduction
- Calculation of tIVT – mention of other parameters – but usually not used acutely on the ICU Tei index calculated here: 580-200/200=1.9 but this doesn’t give me any useful information except that it is increased Tivt very prolonged Ejection time 200msec – 0.2x104=20.8 sec/min Filling time 180msec – 0.28x104= 18.72 Tivt=60-(a+b)=20.20sec I know that both ejection time and filling time are prolonged – both systolic and diastolic performance affected. Delay and prolongation in activation –ischaemia plus activation (lbbb) also diastolic – ischamia. Worsened by the tachycardia may have subendocardial ischaemia even in the absence of obstructive coronary disease.
- Prolonged qrs, looked to do bivent pacing, then looked to minimise tivt using changing vv pacing, and also av delay – resulted in an increase in vti and reduction in tivt (corresponding). Did this all on the ICU. Bivent pacing – then optimisation of HR, AV delay and VV delay to minimise the tIVT and maximise the aortic VTI In our patient: increase in
- Does this work today – yes – one from BME – EDP here, phono also seen Pt on ECMO – seen on right -
- And welcome you to my world – where you will be asked to make complex decisions, under huge time pressure – kit you don’t know, huge amounts of inotropic support, catastrhopic complications you want to avoid/detect – super-low CO states… and all with high amount of pressure and complexity…. And definite risk/uncertainty
- So how badly wrong can it go; other examples of the importance On the top: make the diagnosis Three patients with SARF referred with refractory hypoxaemia, meeting criteria for VV ECMO: echo in both reportedly normal (one by a cardiologist, one by a cardiologist) In the middle 2 more patients re hypovolaemia?: cxr 17 yo man, in the ED in shock, tubed and ventilated – on lying flat peri-arrest – no views (ED, anaesthesia – intensivist – hypovolaemia – actually, RUPV obstruction – moved by .. 3rd on VV ECMO, LV “underfilled” ICU performed echo – acp instead Bottom – illustration of thinking smart using echo Left rv infarction referred for PCI, in cs– very low sv, LV looked empty and hyperdynamic – assumed it was due to this – but transmitral velocities were high – severe MR – surgery (required ECMO) On the right – 6 weeks ventilated, presumed pneumonia, mild MR only – but had dyssynchrony – bivent. Weaned.
- An approach is illustrated - Self explanatory
- Or rather more elegantly put y JR – benefit not the tech skill – intellectual input-
- So my take-home messages are these