Echocardiography for hemodynamic evaluation in the intensive care unit.

Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Shock (Augusta, Ga.) (Impact Factor: 2.73). 09/2010; 34 Suppl 1:59-62. DOI: 10.1097/SHK.0b013e3181e7e8ed
Source: PubMed

ABSTRACT The use of echocardiography in the intensive care unit for patients in shock allows the accurate measurement of several hemodynamic variables in a noninvasive way. By using echocardiography as a hemodynamic monitoring tool, the clinician can evaluate several aspects of shock states, such as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures, and biventricular interactions. However, to date, there have been few guidelines suggesting an objective hemodynamic-based examination in the intensive care unit, and most intensivists are usually not familiar with this tool. In this review, we describe some of the most important hemodynamic parameters that can be obtained at the bedside with transthoracic echocardiography.

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    ABSTRACT: Volume expansion is a mainstay of therapy in septic shock, although its effect is difficult to predict using conventional measurements. Dynamic parameters, which vary with respiratory changes, appear to predict hemodynamic response to fluid challenge in mechanically ventilated, paralyzed patients. Whether they predict response in patients who are free from mechanical ventilation is unknown. We hypothesized that dynamic parameters would be predictive in patients not receiving mechanical ventilation. This is a prospective, observational, pilot study. Patients with early septic shock and who were not receiving mechanical ventilation received 10-mL/kg volume expansion (VE) at their treating physician's discretion after initial resuscitation in the emergency department. We used transthoracic echocardiography to measure vena cava collapsibility index and aortic velocity variation before VE. We used a pulse contour analysis device to measure stroke volume variation (SVV). Cardiac index was measured immediately before and after VE using transthoracic echocardiography. Hemodynamic response was defined as an increase in cardiac index 15% or greater. Fourteen patients received VE, five of whom demonstrated a hemodynamic response. Vena cava collapsibility index and SVV were predictive (area under the curve = 0.83, 0.92, respectively). Optimal thresholds were calculated: vena cava collapsibility index, 15% or greater (positive predictive value, 62%; negative predictive value, 100%; P = 0.03); SVV, 17% or greater (positive predictive value 100%, negative predictive value 82%, P = 0.03). Aortic velocity variation was not predictive. Vena cava collapsibility index and SVV predict hemodynamic response to fluid challenge patients with septic shock who are not mechanically ventilated. Optimal thresholds differ from those described in mechanically ventilated patients.
    Shock (Augusta, Ga.) 02/2013; 39(2):155-60. DOI:10.1097/SHK.0b013e31827f1c6a · 2.73 Impact Factor
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    ABSTRACT: Hemodynamic management in intensive care patients guided by blood pressure and flow measurements often do not sufficiently reveal common hemodynamic problems. Transesophageal echocardiography (TEE) allows for direct measurement of cardiac volumes and function. A new miniaturized probe for TEE (mTEE) potentially provides a rapid and simplified approach to monitor cardiac function. The aim of the study was to assess the feasibility of hemodynamic monitoring using mTEE in critically ill patients after a brief operator training period. In the context of the introduction of mTEE in a large ICU, fourteen ICU staff specialists with no previous TEE experience received 6 hours of training as mTEE operators. The feasibility of mTEE and the quality of the obtained hemodynamic information was assessed. Three standard views were acquired in hemodynamically unstable patients: 1) for assessment of left ventricular function (LV) fractional area change (FAC) was obtained from transgastric midesophageal short axis view, 2) right ventricular (RV) size was obtained from midesophageal four chamber view, and 3) superior vena cava collapsibility for detection of hypovolemia was assessed from midesophageal ascending aortic short axis view. Off-line blinded assessment by an expert cardiologist was considered as reference. Interrater agreement was assessed using Chi-square tests or correlation analysis as appropriate. In 55 patients, 148 mTEE examinations were performed. Acquisition of loops in sufficient quality was possible in 110 examinations for transgastric midesophageal short axis, 118 examinations for midesophageal four chamber and 125 examinations for midesophageal ascending aortic short axis view. Interrater agreement (Kappa) between ICU mTEE operators and the reference was 0.62 for estimates of LV function, 0.65 for RV dilatation, 0.76 for hypovolemia and 0.77 for occurrence of pericardial effusion (all P<0.0001). There was a significant correlation between the FAC measured by ICU operators and the reference (r = 0.794, P (one-tailed) <0.0001). Echocardiographic examinations using mTEE after brief bed-side training were feasible and of sufficient quality in a majority of examined ICU patients with good interrater reliability between mTEE operators and a expert cardiologist. Further studies are required to assess the impact of hemodynamic monitoring by mTEE on relevant patient outcomes.
    Critical care (London, England) 06/2013; 17(3):R121. DOI:10.1186/cc12793
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    ABSTRACT: BackgroundWe studied a score for assessing basic transthoracic echocardiography (TTE) skills exhibited by residents who examined critically ill patients receiving mechanical ventilation.MethodsWe conducted a prospective study in the 16 residents who worked in our medical-surgical ICU between 1 May 2008 and 1 November 2009. The residents received theoretical teaching (two hours) then performed supervised TTEs during their six-month rotation. Their basic TTE skills in mechanically ventilated patients were evaluated after one (M1), three (M3), and six (M6) months by two experts, who used a scoring system devised for the study. After scoring, residents gave their hemodynamic diagnosis and suggested a treatment.ResultsThe 4 residents with previous TTE skills obtained a significantly higher total score than did the 12 novices at M1 (18 (16 to 19) versus 13 (10 to 15), respectively, P = 0.03). In the novices, the total score increased significantly during training (M1, 13 (10 to 14); M3, 15 (12 to 16); and M6, 17 (15 to 18); P < 0.001) and correlated significantly with the number of supervised TTEs (r = 0.68, P < 0.0001). In the overall population, agreement with experts regarding the diagnosis and treatment was associated with a significantly higher total score (17 (16 to 18) versus 13 (12 to 16), P = 0.002). A total score ≥ 19/20 points had 100% specificity (95% confidence interval, 79 to 100%) for full agreement with the experts regarding the diagnosis and treatment.ConclusionsOur results validate the scoring system developed for our study of the assessment of basic critical-care TTE skills in residents.
    04/2014; 4:12. DOI:10.1186/2110-5820-4-12

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