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.
Prof Vieillard-Baron delivered this lecture and began by pointing out a great overall review on the topic https://t.co/5TZsRZIZ12
1: pulmonary embolism – management strategies here https://t.co/Cwc7drmG5z
2: Acute myocardial infarction
3: Mechanical ventilation – especially if a PFO is recanalised https://t.co/NwC6XPI91H
4: ARDS (https://t.co/pVj3GBSJnE)- here are some expert guidelines to manage haemodynamics https://t.co/VJjyQbbZnA
5: chronic RV failure- differentiate this from acute using RV wall thickness and the PASP (again, 5 minute sono has a wonderful example https://t.co/hmDtjSNZJ6)
If your RV is failing, Prof Vieillard-Baron recommends noradrenaline as it’s “magic for the RV”!
Prof Anthony McLean from the Nepeam in Sydney delivered this excellent masterclass using a case from his unit as an example.
Assessing RV function using echocardiography is not easy- the gold standard is MRI https://t.co/CcJ0nBrDTP
There are a number of tools available to us as echocardiographers to monitor RV function:
RV:LV ratio https://t.co/d3eskf2N5n
Spectral Doppler through the right ventricular outflow tract
Fractional area change https://t.co/EerYxVytB0
myocardial performance index (Tei index) https://t.co/IEGrCMdkdk
Tissue Doppler imaging
Tricuspid annular plane systolic excursion (TAPSE)
And indirectly using the tricuspid regurgitation jet and IVC size/collapsibility.
The American society of Echocardiography has excellent guidelines on full assessment of RV function https://t.co/1llzJSBszL which are reviewed and simplified by Cardioserv here https://t.co/Mz49Il1Oq0
ARDS has its own set of challenges and RV function needs to be assessed in conjunction with LV function https://t.co/JUkxw8HNN4
Prof McLean’s advice: measurements are all well and good but can be misleading in practice…
RV assessment is complex. Both subjective and objective parameters are necessary to quantify its function. Be careful with patients on inotropes as they confound things.
Prof McLean’s daily “go-tos” are TAPSE, TR/PASP. If still unsure, he adds FAC and TDI (S’).
Upcoming methods in future: speckle tracking/strain https://t.co/hNRuU6NDTg with reference values here https://t.co/GKq9dyeBYx
Prof reckons if you have a machine in your unit that currently measures strain, you should start using it as it will become mainstream in a few years time…
The ESICM Vienna mega-conference that is #LIVES2017 kicked off Saturday morning with a number of workshops and courses – of course many people are here preparing for the EDIC exam today (Monday), and so there are prep courses running for that – Marco Maggiorini from Zurich, Switzerland gave the opening talk today on heart lung interactions followed by Cardiogenic shock from the emphatic Frenchman Jean-Louis Teboul from Kremlin-Bicetre; see this thread:
All of these sessions are a run through of basic physiology and science, its clinical significance and aim at preparing people for the exam. They finish with MCQs that you can vote with your app for which is a really neat feature:
Stay tuned for more blogs and tweets from the #LIVES2017 SoMe team!