(BQ) Part 2 book Echocardiography for intensivists has contents: Intraoperative echocardiography in cardiac surgery, general hemodynamic assessment, hypovolemia and fluid responsiveness, suspicion of pulmonary embolism, chest pain, acute dyspnea, unexplained hypoxemia,.... and other ocntents.
Part IV Echocardiography in the ICU and OR: Basic and Advanced Applications Echocardiographic History, Echocardiographic Monitoring, and Goal-Directed, Focus-Oriented, and Comprehensive Examination 23 Armando Sarti, Simone Cipani, and Massimo Barattini 23.1 What Kind of Examination? Echocardiography is applied in the emergency and ICU setting according to specific needs as follows First, ultrasonographic examination of the patient This assessment by transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) is performed systematically, according to a logical and reproducible sequence which includes all major cardiovascular structures and measurements from all echocardiographic views Chronic findings, such as hypertrophy or left-sided heart dilatation, must be distinguished from acute changes in order to reconstruct the morphofunctional history of the patient’s heart Further examination to reassess the patient This is more targeted to obtain more specific information and is done in order to follow the evolution of the clinical picture and the response to drugs and general treatment over time, including mechanical positive pressure ventilation Focus-oriented or goal-directed clinical interrogation and assessment This occurs any time during the clinical course of hospitalization in order to resolve a specific question or problem A focus-oriented or goal-directed examination A Sarti (&) Department of Anesthesia and Intensive Care, Santa Maria Nuova Hospital, Florence, Italy e-mail: armando.sarti@asf.toscana.it is not a basic assessment, but is an examination specifically designed to support the making of quick decisions in relation to the diagnosis and treatment following a logical algorithm or predefined flowchart This Chapter and Chaps 24–41 deal with many focus-oriented and goal-directed assessments Rapid emergency examination For very unstable patients the ultrasonographic assessment will only concentrate on the essential information that can be obtained in a few minutes or even seconds Examples are the focused assessment with sonography in trauma (FAST) examination (see Chap 46), designed to help in the diagnosis of and the treatment plan for the traumatized patient, and the focused emergency echocardiography in life support (FEEL) examination (see Chap 42), used to obtain a rapid diagnosis and an immediate intervention, such as the administration of epinephrine, a pericardium drainage, or a fluid bolus during advanced life support 23.2 Operator’s Skill An inexperienced operator will be limited in terms of what he/she is able to obtain and interpret and will need to seek help with any questions or doubts As the intensivist’s skills improve progressively, he/she will be able to enhance his/ her ability to use diagnostic ultrasonography in assessing and treating critically ill or injured patients A Sarti and F L Lorini (eds.), Echocardiography for Intensivists, DOI: 10.1007/978-88-470-2583-7_23, Ó Springer-Verlag Italia 2012 221 222 Cholley et al [2] have set out a pyramid for the progressive acquisition of echocardiographic expertise by intensivists At the base there are the less experienced workers, ideally all ICU physicians, who are required to recognize: • Large pericardial effusion • The diameter of the inferior vena cava and its changes throughout the respiratory cycle • Right ventricular (RV) dilatation • An evident left ventricular (LV) dysfunction • Basic ultrasonographic appearance of the pleura and lung At the center of the pyramid we find operators with more advanced training who are able to: • Detect severe valvular dysfunction • Measure RV (tricuspid annular plane systolic excursion, TAPSE) and LV (fractional shortening, fractional area change, ejection fraction, pulsed wave Doppler measurement of transmitral flow) systolic and diastolic function • Measure the systolic pulmonary pressure • Assess ‘‘fluid responsiveness’’ • Perform thoracic echography At the top of the pyramid we have the skilled operators, of which there is often just one or only a few in each ICU, who have a substantial ‘‘background’’ in cardiology and who are able to use and integrate all the techniques, including Doppler echocardiography and tissue Doppler imaging (TDI), and who can perform the full range of echocardiographic diagnoses and hemodynamic assessments In my opinion, junior intensivists should be trained and certified in performing at least basic heart and lung ultrasonography The standard of training courses and accreditation is highly variable around the world Acceptable competency requires both cognitive and technical knowledge of ultrasound instrumentation, image acquisition, and cardiopulmonary anatomy, physiology, and pathology Enough evidence from the literature shows that reading a book in advance, a TTE/TEE course involving both theoretical and practical training, and ongoing mentoring and supervision after the course can provide a high standard of practice Many scientific societies define procedural competency on the basis of a minimum A Sarti et al number of supervised echocardiographic examinations performed by the intensivist However, regular reaccreditation and continuous comparison with adequate standards are still required to maintain competency A recent international round table of the European Society of Intensive Care Medicine, endorsed by many other societies [6], states that there was a 100 % agreement among the participants that basic critical care echocardiography and general critical care ultrasonography should be mandatory in the curriculum of ICU physicians 23.3 First Comprehensive Examination of the Patient A systematic assessment implies the need for substantial experience and mastery of most of the echocardiographic techniques, including B-mode, M-mode, continuous wave Doppler, pulsed wave Doppler, color flow mapping (CFM), and TDI During the training phase, the intensivist would be better off requesting the intervention of the cardiologist, or another skilful intensivist, so as to perform the first systematic assessment in conjunction with an experienced colleague First, it is advisable to review all previous echocardiographic examinations, if available The comparison is useful to determine the starting point of the patient before the episode that led him/her to the emergency department or ICU Currently observed findings are often very different from those produced previously, even recently In fact, the ICU ultrasound assessment is performed on patients in a critical or unstable condition due to acute changes in arterial pressure, hypovolemia or hypervolemia, hypoxemia, hypercapnia, mechanical ventilation, and high levels of circulating catecholamines This ‘‘stress echocardiography’’ examination may thus show latent disorders which are not visible at rest Echocardiography always starts from the patient and must keep the patient at the center of clinical reasoning Before the echocardiography machine is switched on, the patient’s medical history, the physical examination, and all the 23 Echocardiographic History, Echocardiographic Monitoring, and Goal-Directed, Focus-Oriented results of laboratory and radiographic findings should be reviewed Each operator may follow his or her own particular sequence of image acquisition, so as not to overlook some data With experience, as soon as the operator places the probe on the chest, a general idea of the patient’s heart will be readily obtained Nevertheless, it is better to proceed in a systematic way and then come back to specific views and focus on specific changes in the light of the findings already detected A possible TTE sequence used by the author, with the elements not to be overlooked, is as follows • Parasternal long-axis view: examination of the whole heart, pericardium, measurements of LV outflow tract diameter, left atrium, aortic valve, mitral valve, mitral subvalvular apparatus, CFM Doppler assessment of transvalvular flows and possible regurgitation, RV outflow tract dimension and kinetc dysfunction, 329, 330 Cardiac efficiency, 368, 371 Cardiac mass, 62, 69 Cardiac murmur, 355, 357, 363 Cardiac output, 237, 241 Cardiac tamponade, 105–108, 111, 340 Cardiac tumors, 189, 191, 194, 229, 231 Cardioembolic sources, 192, 367 Cardiomyopathy, 133–139 Central vascular access devices (CVADs), 379 Cerebral vasospasm, 414 Chest pain, 297 Chest ultrasonography, 267 Chiari network, 103 Chordal rupture, 361 Chronic renal failure, 407, 408 Color Doppler, 198–200, 205, 401–403, 406, 408 Color flow Doppler, 183–185 Complications, 409 Comprehensive examination, 52 Compression ultrasound, Congenital heart disease, 207 Congenital septal abnormalities, 197 Constrictive pericarditis, 106, 108, 110, 111 Contrast echocardiography, 198, 204, 321, 322, 324 Contrast media, 395 Contusions, 391 Coronary flow reserve, 247 D Deep vein thrombosis (DVT), 385 Diastolic function, 47, 48 Dilatative, 137 Direct heart damage, 349 Doppler echocardiography, 7, 235, 236, 238, 239 Doppler shift, 8–10 Duke criteria, 177, 178 Dynamic bronchograms, 393 Dyspnea, 313, 314, 316, 319 A Sarti and F L Lorini (eds.), Echocardiography for Intensivists, DOI: 10.1007/978-88-470-2583-7, Ó Springer-Verlag Italia 2012 427 428 E EA/EES ratio, 368, 371, 372 Echocardiographic criteria of fluid responsiveness, 254 Echocardiography, 21, 22, 38, 100–103, 122, 123, 152, 155, 158, 162–164, 328, 329, 331, 343, 345–347, 369, 371 Echo-history, 229, 230 Ejection fraction (EF), 76, 81, 367, 373 Emboli, 181, 182 Emergency medicine, 222, 313 Endocarditis, 353, 359–363 Endotracheal tube, 409, 411 Eustachian valve, 100, 104 Exploratory laparotomy, 397 External work, 368 Extravascular lung water, 313, 316 F FAST, 397 Fibroma, 191, 192, 194 Fluid responsiveness, 258, 259, 261, 262, 265 Focused abdominal sonography for trauma, 397–399 Focus-oriented assessment, 221 Fossa ovalis, 99, 100, 103, 104 Free wall rupture, 355, 356 G Global systolic function, 76, 79, 81 Goal-directed assessment, 221, 222 Graft function, 349 Graft patency, 247 Guidelines, 208 H Heart failure, 279 Heart–lung interaction, 260, 263 Heart–lung interaction in mechanical ventilation, 263 Heart morphology, 51, 52 Hemodynamic instability, 275, 279, 280 Hemodynamic monitoring, 51 Hemorrhagic shock, 336 Hemothorax, 390 Heterotopic heart transplantation, 353 Hypertrophic, 133–136 Hypovolemia, 257–262, 275, 277, 280 I ICU comprehensive echocardiographic examination, 229 Image optimization, 43 Inferior vena cava (IVC), 121 Intensive care echocardiography, 21 Intensive care unit, 21, 272, 275 Interatrial septum, 102, 103 Interstitial-alveolar syndrome, 390 Interventional procedures, 61, 71 Index Interventricular septum shift, 92 Intracardiac shunt, 211, 215 Intracranial hypertension, 417 Ischemia, 125, 126, 129, 131 Isthmus of the aorta, 114, 118, 336 IVA, 146 K Kidney, 401–408 L Leaflet, 151–155, 160–163 Left atrial thrombus, 190 Left atrium, 99–103 Left ventricle, 44, 45 Left ventricular and right ventricular volumes, 62, 63 Left ventricular-arterial coupling, 367, 368, 371–373 Left ventricular diastolic function, 86, 88 Left ventricular filling pressure, 236, 237 Left ventricular function, 75, 78 Left ventricular outflow tract obstruction, 355, 358–360, 363, 364 Left ventricular rotation, 78 Left ventricular thrombus, 194 Levovist, 247 Local anesthesia, 409 Lung consolidation, 314, 315, 390, 394 Lung echography, 313, 314 Lung points, 391 Lung sonography, 216 Lung ultrasound, 270 LV end-systolic pressure-volume relation (ESPVR), 368 M Mean gradient, 184, 185 Mechanical complications of myocardial infarction, 355, 357 Mechanical ventilation, 93 Mechanical work, 368, 371 Metastatic cardiac tumor, 189, 191, 194 Mitral prosthesis, 185, 186 Mitral regurgitation, 126, 127, 129, 135–137, 139 Mitral surgery, 162 Mitral valve, 151, 152 M-mode, 46 Multiorgan donor, 349 Myocardial infarction, 125, 126, 130 Myocardial ischemia, 303, 308, 311, 312 Myocardial performance index, 89 Myocardial perfusion, 245, 247 Myxoma, 191, 192, 194 N Neck study, 409 Non-compaction, 133, 137, 140 Index Noninvasive, 413 Noninvasive hemodynamic monitoring, 370, 371 429 Right Right Right Right to left shunt, 321, 324 ventricle, 45, 49, 208, 215 ventricle failure, 279 ventricular (RV) overload, 197–199 O Optic nerve, 417 P PAP, 143–145 Papillary fibroelastoma, 191 Papillary muscle rupture, 127, 129, 355, 357, 358, 363, 364 Passive leg raising, 260, 261 Patent dutus arterious (PDA), 114, 120, 211 Patent forame ovale (PFO), 199, 245, 321 Pediatric echocardiogram, 205, 206 Penetrating chest trauma, 334 Percutaneous closure, 199, 204 Percutaneous tracheostomy, 409 Pericardial disease, 105 Pericardial effusion, 105–107, 109 Pericardial tamponade, 279, 280 Pericardial tumors, 111 Pericardium, 105–108, 111 Perioperative myocardial ischemia, 250 Peripherally inserted central catheter (PICC), 379 Perivalvular abscess, 181 Perivalvular leak, 162 Pleura, 313–319 Pleural effusion, 314 Pneumonia, 390 Pneumothorax, 313, 314, 319, 390 Pressure gradient, 235–237 Pressure half time, 169 Prosthetic dysfunction, 366 Pulmonary artery, 91–95 Pulmonary artery hypertension (PAH), 197, 198, 202, 204, 205 Pulmonary edema, 314–317, 319 Pulmonary embolism, 283, 297–299, 301–303, 314, 319, 385, 387, 394 Pulmonary hypertension, 95 Pulmonary valve, 171–173 Pulse contour methods (PCM), 370, 371 R Real time 3D echocardiography, 243 Recruitment, 393 Regurgitation, 152, 153, 155–160, 162 Resolution, 3, 5–8 Respiratory failure, 271 Restrictive, 133, 138, 139 Right atrial pressure (RAP), 121, 123 Right atrium, 99, 102, 103 S Sarcomas, 191, 193 Seldinger technique, 409 Sepsis, 327, 328, 330, 332 Septal rupture, 356 Septic shock, 275, 280, 327–329 Shunt, 197–199, 201–205 Sonography, 397 Standard TEE views, 52, 55 Stenosis, 152, 156, 162–164 Strain, 145–148 Strain rate, 145–148 Strain rate imaging, 129–131 Stroke volume, 239 Systolic anterior movement, 280 Systolic function, 46–49 T TAPSE, 144 TDI, 145–149 TEE guidelines, 52 TEE probe, 207 Tei index, 147 The right ventricle, 91–97 Three-dimensional echocardiography, 324 Thrombosis, 386–388 Tissue Doppler, 46–49 Tissue Doppler imaging, 81–83, 88, 130 Tissue Doppler-strain and strain rate, 208 Transesophageal, 152, 162 Tranesophageal echocardiography (TEE), 51, 57, 114–117, 126, 211, 213, 214, 216, 228–233, 249, 289–292, 294, 298–300, 302, 306–309, 311, 322, 324, 333–335, 337, 338, 339, 343, 361 Transcranial Doppler, 413–415 Transesophageal three-dimensional echocardiography, 61, 69 Transthoracic, 152 Transthoracic echocardiography (TTE), 126, 127, 298, 307, 308, 322, 324 Transthoracic examination, 23 Transthoracic three-dimensional echocardiography, 61, 67 Traumatic aortic injury, 333, 336, 337 Tricuspid valve, 171, 172 Tricuspid valve regurgitation, 284 TTE echocardiographic views, 40 Two-dimensional echocardiography, 241, 243 430 U Ultrasound, 345, 379–382, 401, 405, 406, 409 Ultrasound contrast agents, 245 Ultrasound of the heart, 23 Ultrasound physics, Unexplained hypoxemia, 321 Unstable patient, 363–365 US hemodynamic assessment, 222, 345 V Valve diseases, 62, 66, 68 Valvular anatomy, 152 Index Vegetations, 177–179, 181 Vena contracta, 168, 169 Ventilation, 269, 271, 273–275, 277 Ventricular elastance, 367 Ventricular septal defect (VSD), 198, 200–205 W Wall motion abnormalities, 125 Weaning, 269, 271–273 ... strain rate, 20 8 Transesophageal, 1 52, 1 62 Tranesophageal echocardiography (TEE), 51, 57, 114–117, 126 , 21 1, 21 3, 21 4, 21 6, 22 8 23 3, 24 9, 28 9 29 2, 29 4, 29 8–300, 3 02, 306–309, 311, 322 , 324 , 333–335,... 10.1007/978-88-470 -25 83-7, Ó Springer-Verlag Italia 20 12 427 428 E EA/EES ratio, 368, 371, 3 72 Echocardiographic criteria of fluid responsiveness, 25 4 Echocardiography, 21 , 22 , 38, 100–103, 122 , 123 , 1 52, 155,... and F L Lorini (eds.), Echocardiography for Intensivists, DOI: 10.1007/978-88-470 -25 83-7 _23 , Ó Springer-Verlag Italia 20 12 221 22 2 Cholley et al [2] have set out a pyramid for the progressive acquisition