Basic Echocardiography Masterclass at LIVES3019
Here an infographic with some tips about running a (basic) point-of-care cardiac ultrasound study in the critical care patient. The 5 main views:
parasternal long axis – PLAX
parasternal short axis – PSAX (mitral valve, papillary muscles, apex & great vessels level)
apical 4 chambers – A4C
apical 2 chambers – A2C
subcostal (4 chambers and vena cava views)
are summarised with advices in probe positioning in order to find the acoustic window, and some notes about the data potentially achievable, regarding LV, RV, pericardial fluid, volume status & others. Enjoy and follow #LIVES2019 hashtag on twitter for full virtual access to the annual ESICM congress.
graphics Marta Velia Antonini @FOAMecmo
echocardiographic scans Jonny Wilkinson @Wilkinsonjonny criticalcarenorthampton.com
content based on A. McLean & Y. Beaulieu class at #LIVES2019
*This webinar was kindly sponsored by GE*
We would love to hear from you and any feedback/questions would be welcomed. OR if you want to find out more about #POCUS fellowships……
What is #POCUS
Lichtenstein D, van Hooland S, Elbers P et al. Ten good reasons to practice ultrasound in critical care.
Lichtenstein D and Mezière G (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure. The BLUE-protocol.
Perera P, Mailhot T, Riley D et al. The RUSH exam: Rapid ultrasound in shock in the evaluation of the critically ill.
Lichtenstein D.A. Lung Ultrasound as the First Step of Management of a Cardiac Arrest: The SESAME-Protocol. In: Lung Ultrasound in the Critically Ill. Springer, 2016 Cham
Training in #POCUS
Malbrain MLNG, De Tavernier B, Haverals S et al. Executive summary on the use of ultrasound in the critically ill: consensus report from the 3rd Course on Acute Care Ultrasound (CACU).
Mayo P, Beaulieu Y, Doelken P et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography.
Expert Round Table on Ultrasound in ICU. International expert statement on training standards for critical care ultrasonography.
Wong A, Galarza L and Duska F. Critical Care Ultrasound: A systematic review of international training competencies and program.
Galarza L, Wong A and Malbrain M. The state of critical care ultrasound training in Europe: A survey of trainers and a comparison of available accreditation programmes.
Future of #POCUS
Robba C, Goffi A, Geeraerts T et al. Brain ultrasonography: methodology, basic and advanced principles and clinical application. A narrative review.
Aitkinson P, Beckett N, French N et al. Does point-of-care ultrasound use impact resuscitation length, rates of intervention and clinical outcomes during cardiac arrest? A study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators.
Feng M, McSparron JI, Kien Dt et al. Transthoraccic echocardiography and mortality in sepsis: analysis of MIMIC-III database.
If you are REALLY interested in pushing the limits of ultrasonography in critical care … https://thinkingcriticalcare.com/
Inferior Vena Cava may appear congested when it’s dilated without any respiratory variation collapsed with very small diameter through the respiratory cycle, or compliant and vary through respiratory cycle. But how IVC looks like depends on how the patientis breathing, spontaneouslyvs mechanically ventilated.
During spontaneous breathing, in inspiration there is a decrease in pleural pressure, partially transmitted to the heart chambers with a decrease in Right Atrial Pressureand increase in Venous Return (the lower the RAPthe easier the venous return). Because of this decrease in RAP there is a decrease in IVC transmural pressure the size (diameter) and a decrease in size of IVC.
To give numbers, a 40% variation in spontaneouslybreathingpatients is usually associated to preload responsiveness: patient will respond to fluids (but it does not mean that he needs fluids: gives only if associated hypotension/poor perfusion).
In patients with positive pressure ventilation physiology is completely reversed: you put positive pressure in the thorax, this is partially transmitted to the heart chambers whit an increase in RAP, an increase in IVC transmural pressure and in IVC diameter. We expect a dilated and non compliant Vena Cava due to the impeded venous return, collapsible vena cava is an abnormal finding. If you observe a compliant Vena Cava n a patient on MV, changing diameter with ventilation, actually increasing diameter with insufflation due to raised pressure in thorax impeding venous return and flattening in expiration with pressure release), this means that probablythis patient has volume in the veins that can be recruited. A > 12-18% variation in mechanically ventilated patientis usually associated to preload responsiveness(Feissel et al. 2004 http://bit.ly/2Cvm6Fp; Barbier et al. 2004 http://bit.ly/2Pb8R3p).
In patients with elevated Intra-Abdominal Pressure IVC is not interpretable anymore.
The endpoint of resuscitation is improve tissue perfusion, not to increase IVC diameter. The respiratory variations in large vessels just attest that there is some stressed volume that can be recruited: is vein collapses there is room to expand a little more and by increasing the stressed volume there is an high probability to increase the venous return and cardiac output if you think this in needed.And remember: IVC measurement really simple but not make the vena cava say what it can’t say.
Pictures from Cholley B talk at #LIVES2018
It was delightful listening to Paul Mayo deliver this excellent talk based on his clinical experience.
Critical care echocardiography is a different beast to the traditional “echo lab” approach favoured by cardiology. Our environment does not lend itself well to hour long studies per patient recording every measurement.
His unit adopts a flexible approach, deploying aspects of advanced echo as needed to answer specific clinical questions. Occasionally a full study will be performed. For quality control reasons, all their TOEs (TEEs) are full studies.
NYC is staffed by 10 attending and 6 “night owls”, all of whom are competent in general critical care ultrasound. 3 of the team are competent in advanced echo.
As an example of how they apply advanced skills, All shocked patients will get VTI to estimate stroke volume. Other measurements are used selectively such as:
- E/e’ to estimate filling pressures
- Bubble studies for hypoxemia
- Quantitative studies of valve function
- Precise measurements of RV function (PASP, PADP, PAMP, RV S’, PAT, TAPSE)
- Regional wall motion abnormality assessments
- serial echoes for dobutamine or nitric oxide trials
Images are saved, and relevant findings documented in notes (except TOEs which all get a ful, report). Interesting cases are discussed at a weekly meeting.
For those training in advanced CCE, Mayo recommends ALL views and ALL measurements are performed in a specific sequence, and images rejected if they are suboptimal. Not only does it upskill the user, it brings credibility to the field and reassures our cardiology and imaging colleagues.
These were certainly useful points that all of us in the critical care and imaging community should take note of.