Echocardiography in the ICU by tdc38363


									Echocardiography in the ICU

                    James Lai
               Dept of Anaesthesia
              Auckland City Hospital
           Evolution in Echocardiography

Novice                                                 Expert
                          Cardiac Anaesthesiologist
  Surgeon ED Physician Intensivist Anaesthesiologist
You CAN do echo!
                          When - Indications ?

         Traditional approach based on clinical signs

Range and prevalence of cardiac abnormalities in
patients hospitalized in a medical ICU - clinical
investigations in critical care CHEST,  Oct, 2002  Eduardo
Bossone,  Bruno DiGiovine,  Sara Watts,  Pamela A. Marcovitz,  Louise Carey,  Charles
Watts,  William F. Armstrong

TTE 467 patients - 169 had cardiac abnormalities (36%)
Abnormalities                                No.

Significant LVH                              53
Moderate or greater valvular insufficiency   46
Pulmonary Hypertension                       38
Myocardial ischemia/infarction               34
Significant LV dysfunction EF < 35%           25
LA diameter > 5 cm                           17
Moderate or greater pericardial effusion     15
Valve vegetations                            12
Dilated RA                                   11
LV thrombus                                   8
Moderate or greater valvular stenosis         8
Dilated RV with overload pattern              6
Aortic root diameter > 4 cm                    3
Intracardiac shunt                             3
LVOT gradient > 40 mm Hg                       2
Aortic dissection                              1
How - Techniques
     FAST scan
Bedside Limited Echo
FAST - Focussed Abdominal Sonography
               Clinical Case

•   65 yr old female pedestrian struck by a car

•   Hypotensive BP 70/40 HR 95 3L fluid given

•   #Femur #Pelvis Soft Abdomen Alert GCS 15

•   Becoming breathless RR 26

•   Awaiting Xrays and Bloods
Limited Bedside Echocardiography Performed By
Intensivists in the Medical ICU Chest 128 (4): 207S. 2005
Roman Melamed, MD*, Steven Hanovich, MD, Robert Shapiro,
MD, Mark Sprenkle, MD, Valerie Ulstad, MD and James
Leatherman, MD

Bedside Limited Echocardiography by the Emergency
Physician Is Accurate During Evaluation of the Critically
Ill Patient Pediatrics 10 : 1542 2004
Jay Pershad, MD*,, Sharon Myers, Cindy Plouman, Cindy
Rosson, Krista Elam, Jim Wan, PhD and Thomas Chin, MD,
            Bedside Limited Echo

•   Haemodynamic assessment by TTE

•   2 views - subcostal and parasternal SAX view

•   IVC diameter as a predictor of CVP

•   LV Function assessed in SAX view

•   Studies show it is accurate and teachable
                IVC size vs CVP

        SIZE          COLLAPSE                CVP (mmHg)
Small      <1.5cm

Normal 1.5 – 2.5cm
          5 - 10

Normal 1.5 – 2.5cm
          10 –15

Dilated    > 2.5cm
          15 – 20

Dilated 	    	           no collapse	 	 	 	     > 20
+ dilated hepatic veins	
Parasternal Short Axis
4.8   3.2
FS % = 4.8-3.2
    x   100 = 33 %
   Normal >28%
         63 yr old postop AAA repair
Hypotension with escalating inotrope requirement
 6 Segments at MID SAX Level

                               A    Anterior
      AS             L
                               L    Lateral
 RV                            P    Posterior
                               I    Inferior
      IS                       S    Septal
                               AS   Anteroseptal

RCA        Cx            LAD
                    Cardiac output

Stroke volume = area x velocity
time integral

Area = πr2 or 0.785 x D2 for circular
structures like LVOT

VTI or TVI = Velocity Time Integral

CW or PW at LVOT, aortic, mitral,
tricuspid, pulmonary valves
D = 2.77 cm             VTI = 15cm

                   2 = 6 cm2
Area = 0.785 x 2.77
Stroke Volume = Area x VTI
Stroke Volume = 6 x 15 = 90mls

Cardiac Output = 90 x 60 = 5.4 L/min

        10 Oesophageal
        DAYDoppler Probe

                          with the

                                 Premium Solution
                                 For Cardiac Output Monitoring
                                 and Fluid Management in
                                 Critical Care and Medium to
                                 Long Duration Surgery
                                 ODP is ideal for:
                                 • Pre and Peri-optimisation for surgery
                                 • ITU monitoring
        Quick Easy Safe          • Single probe to follow patients from
                                   A&E into Theatre then ITU
                                 • Peri and Post surgical optimisation in
                                   medium duration surgery
Point of Care Haemodynamic Assessment

•   More than BLEEP - Using TTE or TOE

•   Royce et al. University of Melbourne

•   7 basic haemodynamic states

•   4 steps to the method

•   ?BP ?Pulmonary oedema ?Low CO ?Acidosis
Point of Care Haemodynamic Assessment

•   Estimate volume status

•   Measure ventricular function

•   Estimate LAP

                Safety   Valves   Ventricles   Aorta

TOE    ++        +       ++         ++         ++

TTE     +       ++        +          +          +
74 yr old female postop laparotomy - perforated colon
      RR 26 CVP 14 Poor urine output BP 75/44
              Fluid or Inotropes or both?
Estimate Function

        6.6         6.0
Estimating LAP



                Derive haemodynamic state

                    Volume     Function     LAP

     Empty                       N
Diastolic Failure                N
Systolic Failure                            N
 S + D Failure

   RV Failure

  Vasodilated                    N
Echocardiography in the critically ill: current and potential roles
Intensive Care Med Vol 32 No 1 Jan 2006
Price S, Nicol E, Gibson DG, Evans T

Echocardiography in the ICU: time for widespread use
Intensive Care Med Vol 32 No 1 Jan 2006 Editorial
Bernard P. Cholley1 , Antoine Vieillard-Baron2 and Alexandre Mebazaa

“Echocardiography...can be a life-saving tool”
“Echocardiography should be available 24 hrs a day”
        TOE - training requirements

•   Formal training programme recommended

•   Cardiac Anaesthesia Fellowship

•   50-150-300 TOEs 3 levels competency

•   NBE PTE exam U.S (Echo boards)

•   Postgraduate Diploma TOE University of
         TTE - training requirements

•   Formal training - ?Fellowship ?Attachment

•   ASE SCE exam (US)

•   Point of Care, AIUM, Phillips, BATS

•   Haemodynamic assessment vs diagnostic
Point of care ultrasound for basic haemodynamic assessment: novice
compared with an expert operator
Anaesthesia 2006 61 849-855
CF Royce, JL Seah, L Donelan, AG Royce

4 weeks of novice training by an expert echocardiography technician
10 training sessions
Acceptable agreement of novice with expert after 20 to 40 studies

We recommend a minimum of 20 training studies prior to clinical use
      U LTRA S O U N D
                  w       o           r             k          s               h          o          p
                               n              o           t           e            s
   Ultrasound Physics        Vascular Access                 Regional Anaesthesia          Haemodynamics
   An introduction           Ultrasound-guided central and   Ultrasound-guided brachial    FAST scan, Bedside Limited
   Dr Lenore George          peripheral vascular access      plexus blockade               Echocardiography
   Dr James Lai              Dr Chris Nixon                  Dr Neil MacLennan             Dr James Lai
   Page 1                    Page 7                          Page 10                       Page 13

AACA Pre-conference Workshop
Perioperative Ultrasound
November 5-6th 2006

Ultrasound Physics

The sound waves used diagnostically in ultrasound have a frequency of >
1MHz, whereas the audible range for humans is 20 Hz to 20 kHz.
Sound waves are propagated through a medium by the vibration of molecules
(longitudinal waves). Within the wave, regular pressure variations occur with             A basic knowledge of ultra-
alternating areas of Compression, which correspond to areas of high pressure
A Hands-On Approach to
Transthoracic Echocardiography
for the Intensivist & Anaesthetist
Preliminary announcement
Wednesday November 22 - Friday 24 November 2006

The Sebel Hotel
Pier O ne
11 Hickson Road, SYD NEY 2000

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