Downloaded 110 times
Uploaded bySMACC Conference
The Echo Doesn't Lie by Murphy
The document discusses the role of echocardiography (echo) in assessing hemodynamics and the complexities of using echocardiographic measurements in critically ill patients. It highlights the assumptions and limitations of different echocardiographic methods, emphasizing the importance of accurate measurement techniques to avoid errors in cardiac function assessments. Additionally, it covers various parameters used to evaluate fluid responsiveness and the impact of interventions in specific clinical scenarios.
In this document
Powered by AI
Introduction to Deirdre Murphy Alfred ICU, discussing the truth and assumptions regarding echocardiography.
Emphasizes understanding limitations and methodologies in echographic assessments, including common hemodynamic information. Discusses achieving good Doppler traces, understanding flow patterns, and maintaining accurate measurements through various views.
Explores the evaluation of right-sided cardiac output and pulmonary acceleration time for PA pressure estimation.
Investigates early studies on left atrial pressure estimates from IVC dimensions, important for assessing volume states.
Functional evaluation of hemodyanamics, including IVC distensibility index and the predictive value of passive leg raises.
Assessment of fluid responsiveness in patients using echo to determine ventricular stroke volumes and intrathoracic pressure effects.
Analysis of LV function, including methods, complexities of measurements, and echocardiography as a dynamic hemodynamic tool.
Presents a case study of a patient post-surgery, discussing differential diagnosis and the role of echo in hemodynamic management.
More Related Content
Similar to The Echo Doesn't Lie by Murphy
The Echo Doesn't Lie by Murphy
- 1. DEIRDRE MURPHY ALFREDICU THE ECHO DOESN’T LIE
- 2. ECHO DOESN’T LIEBUT IT CAN BEND THE TRUTH A LITTLE
- 3. ECHO IS BASEDON A NUMBER OF ASSUMPTIONS
- 4. ECHO IS BASEDON A NUMBER OF ASSUMPTIONS Sound travels at same speed though all tissues (It doesn’t) Echoes are generated from centre of the beam !
- 5. ZOETROPE TY THETASMANIAN TIGER
- 6. Important in utilisingthe technology that we understand the limitations so that we can use it to its full potential
- 7. COMMON HAEMODYNAMIC INFORMATION and the pitfalls in their measurement..
- 8. CARDIAC OUTPUT fundamentalmeasure in critically ill patient
- 9. LVOT method Assumesthe LVOT is a cylinder We can measure the VTI of blood flow in the LVOT by placing a pulse wave doppler gate in LVOT This gives us the LVOT VTI
- 10. MATHS… Volume =CSAX height (distance) ! Stroke volume= π r2 X VTI ! Cardiac output= SV x heart rate
- 11. any measurement errorwill be squared ! CSA= π r2
- 12. Major pitfalls ! Flow acceleration at valve-measure 1 cm back Ensure line up with cursor-inaccurate if >10°
- 13. USE VIEW WITHTHE BEST DOPPLER LINE UP- DIFFERENT FOR DIFFERENT PATIENTS 5 chamber view 3 chamber view
- 14. HOW DO YOUKNOW YOU’VE GOT A GOOD DOPPLER TRACE PW Doppler spectral outline Trace not “filled in”- in moving front of blood flow Not jagged feathery ends
- 15. Measurement of VTIor stroke distance Average 3 in sinus rhythm Average 5 if arrhythmia
- 17. THE LVOT ISELLIPSOID ! ! ! !
- 18. AGREEMENT WITH THERMODILUTION Reasonable Operator needs to be aware of the sources of error !
- 19. Patient commenced onadrenaline after study LVOT measured at 1.0 cm, VTI N LVOT in adult 1.8-2.6
- 20. RVSP (PA PRESSUREESTIMATION) Based on Bernoulli equation Pressure gradient =4V2 RVSP= PG + CVP PA pressure = RVSP
- 21. WHAT ARE THEREQUIREMENTS? Need to evaluate in a number of views to get the best line up with the colour jet
- 22. R SIDED CARDIACOUTPUT Useful to quantify shunts, MCS RVOT inflow velocites lower and vary with respiration
- 23. PA Diastolic (PRjet) 8 mm (+ RAP) mmHg PA pressure estimation from Pulmonary Acceleration time
- 24. WHAT ABOUT VOLUMESTATE AND ECHO?
- 25. EARLY STUDIES LOOKEDAT LVEDA Problems as doesn’t take into account compliance afterload states
- 26. STATIC ESTIMATES OFR ATRIAL PRESSURE AND ECHO IVC dimension (spontaneous breathing) and collapsibility ! IVC = <2.1 and varies > 50% Estimated RAP =3 In between =8 IVC = > 2.1 and doesn’t vary Estimated RAP =15
- 27. L HEART PRESSURES Echo assessment of left atrial pressure ! Mitral valve E/e’ E/A > 2 PAOP >18 ! E/e’ > 15 PAOP > 18
- 28. SO MUCH FORSTATIC PARAMETERS..
- 29. FUNCTIONAL HAEMODYNAMICS Describingthe effects of cardiorespiratory interactions in positive pressure ventilation
- 30. IVC distensibility index Change in IVC with positive pressure ! > 18% significant ! Sensitivity 90% Specificity 100% – Cut off of 18% –Max IVC D-min IVC D/ Mean IVC D Max IVC diameter-min IVC diameter/ mean IVC diameterFeissel et al ICM 2004
- 31. SVC collapsibility Vuseful as intrathoracic TOE >36% significant Max-Min/Max value Viellard-Baron et al ICM 2004
- 32. PULSE PRESSURE VARIABILITY/STROKE VOLUME VARIABILITY Can assess with echo Need to be v entilated Sinus rhythm
- 33.
- 34. Volume responsiveness andecho using passive leg raise VTI =19 VTI =27 45% Change in VTI (SV) of 12% predicts fluid responsiveness Lamia et al ICM 2007. Monnet at al CCM 2006
- 35. Mandeville. Can TransthoracicEcho be Used to Predict Fluid Responsiveness in Critically Ill? Crit Care Research and Practice 2012
- 36. 3 HEART BEATS INSPIRATION POST INSPIRATORY DROP IN LV OUTPUT ONLY IF VOLUME RESPONSIVE
- 37. BENEFIT OF USINGECHO assess for false positives
- 38. WOULD YOU GIVEFLUID TO EITHER OF THESE PATIENTS?
- 39. A VOLUME RESPONSIVENESSSTUDY WILL TELL YOU BOTH
- 40. Increase intrathoracic pressure Increase RV after load Decreased RV stroke volume Decrease LV stroke volume
- 41.
- 42. ECHO ASSESSMENT OFLV FUNCTION
- 43. FRACTIONAL SHORTENING ! many assumptions inaccurate if wall motion abnormality any errors in measurement will be cubed for EF measurement
- 44. BIPLANE SIMPSON’S 1.Trace ED area A4C 1. Trace ES area A4C
- 45. BIPLANE SIMPSON’S 3.Trace ED area A2C 4. Trace ES area A2C
- 46.
- 47. 3D ECHO Impressivepictures and more accurate quantification
- 48.
- 49. RV SYSTOLIC FUNCTION TAPSE >1.6cm (Tricuspid Annular Plane Systolic Excursion)
- 50. RV SYSTOLIC FUNCTION S’ > 10 cm/S N
- 51. SO WHY USEECHO AS A HAEMODYNAMIC TOOL?? Tells you what the problem is currently (not just the haemodynamic effects of the problem) ! What’s causing it ! If what you are doing about it helps
- 52. CASE STUDY 72yo man post CAGs X 2 and AVR “Good” LV intra-operative Hypotensive MAP 65 PAC: CO 3.6/ C.I 1.8 PA pressures 56/30 CVP 18 Management? Inotropes and vasopressor: Milrinone 10 mcg/min, adrenaline 7 mcg/min, Noradenaline 17 mcg/min
- 53. DIFFERENTIAL ? Tamponade ? Graft ischaemia
- 59. Dx LV outflowtract obstruction (with SAM) Rx: Avoid hypovolaemia Avoid inotropy Maintain afterload
- 62. DYNAMIC LVOTO Seenafter cardiac surgery classically AVR Seen in non-cardiac surgery patients also esp elderly females with hx HTN and DM Haemodynamic situation worsened by inotropes and can contribute to downward spiral
- 63. SUMMARY Echo playskey role in assessment of haemodynamics Helps identify false positives in terms of volume responsiveness Adds a subtlety to the haemodynamic assessment Is user dependant and like any tool is more powerful when used optimally