Evidence based of hemodynamic ultrasound in critically ill patients - อ.พญ.สุธาพร ล้ำเลิศกุล

1. Hemodynamic ultrasound in
critical care
Suthaporn Lumlertgul M.D.!
Emergency unit, King Chulalongkorn Hospital!
WINFOCUS Thailand director

2. Circulatory failure
Persistent shock despite initial
therapy
Main Mechanism of shock
Complicated AMI
RWMA, LV dysfunction, RV
involvement, mechanical
complication
Complicated acute coronary
syndrome
Tamponade, acute aortic
regurgitation, LV dysfunction
Massive Pulmonary Embolism Acute corpulmonale
Cardiac tamponade
Circumferential compressive
pericardial effusion

3. RUSH - every organ except Gyne
POCUS - every organ except lung effusion
FEEL- Heart
FATE - Heart+ Pleural effusion

5. shock
Hypovolemic Distributive Cardiogenic Obstructive
Collapsed IVC Large IVC
Small hyperdynamic LV Hypodynamic LV Tamponade
PE
Tension PNX
CHF

11. Effusion(Pericardial)
Ejection fraction
EYEBALL, EPSS
Equality(Pulmonary embolism)

12. Effusion(Pericardial)
Ejection fraction
EYEBALL, EPSS
Equality(Pulmonary embolism)

13. Circumferential
compressive
pericardial effusion

16. https://web.stanford.edu/group/ccm_echocardio/cgi-bin/
mediawiki/index.php/Tamponade

17. https://web.stanford.edu/group/ccm_echocardio/cgi-bin/
mediawiki/index.php/Tamponade

19. Tamponade
PE
RV
IVS
MV
PW

20. normal M mode from http://
collapse of the RV during diastole.
ventricular
P
R
IV
M
P
}diastol

23. X X

24. MV
RV

25. Effusion(Pericardial)
Ejection fraction
EYEBALL, EPSS
Equality(Pulmonary embolism)

26. LV Function
• Global hypokinesis = reduced EF
• Do not need a number
• Normal (>50%)
• Decreased (30-50%)
• Severely decreased (<30%)
• Things to look for
• Wall movement--change in ventricular area
• Wall thickening
• MV anterior valve movement (2-7 mm normal)
Weekes AJ, Zapata RJ, Napolitano A. Symptomatic Hypotension: ED Stabilization and the Emerging Role of Sonography. Emergency Medicine
Practice. Nov 2007, Vol. 9, No. 11.

27. Compare eyeball(3 grade) to actual measure

28. LV Function--Sepsis

29. Inward motion of
the endocardium
Longitudinal motion of
the mitral annulus
Thickening of the
myocardium
Geometry of the ventricle

32. End Point Septal Seperation

33. End Point Septal Seperation

34. RV Dysfunction

37. RV Dysfunction
• Other signs of PE
• Septal flattening / LV imprairment
• McConnell sign
• PA pressures
• Tricuspid Regurgitation
• Right atrial enlargement

38. Volume responsive assessment tools

39. Volume independent
First Diagnosis
รับ refer, load มาแล้วสักพัก
use CVP, RV, LV size,
PAOP

40. Clinically suspected hypovolemia
fluid-responsiveness approach
Mechanically ventilated patient Spontaneous breathing patient
Passive leg raising

41. Mechanically ventilated
patient
TTE
Sinus rhythm Arrhythmia
Passive leg raising Distensibility IVC
Aortic blood flow

42. Lamia et al. demonstrated in 24 patients that PLR induced an
increase in SV of 12.5% or more predicted an increase in SV
of 15% or more after volume expansion with a sensitivity of
77% and a specificity of 100%