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Pitfalls of Echocardiography as a
Haemodynamic Monitoring Tool
A/Prof Ian Seppelt FANZCA FCICM
Dept of Intensive Care Medicine, Nepean Hospital,
University of Sydney
George Institute for Global Health, University of NSW
Faculty of Medicine and Heath Sciences, Macquarie University
Haemodynamic Monitoring by Echo– Presenter
Disclosure
• No conflicts to disclose
• Thanks to Drs Sam Orde, Marek Nalos and Martin Stefan
Prehistoric
Intensive Care
The value of bedside ultrasound
• Echocardiography
• Thoracic ultrasound
• Vascular access
• Neural blockade
• Hepatic and renal
ultrasound
• FAST in trauma
• Pretracheal ultrasound
Characteristics of „Point of Care
Ultrasound‟
• Exam is for a well-defined purpose
linked to improving patient outcomes
• Exam is focused and goal-directed
• Exam findings are easily recognizable
• The exam is easily learned
• Exam is quickly performed
• Exam is performed at the patient‟s
bedside
From 2014 all trainees must demonstrate
competency in basic echocardiography.
In order for the Trainee to fulfil this requirement,
satisfactory completion of the following is required:
(a) Attend an accredited course in basic echocardiography
(b) Perform, document and appropriately interpret 30 basic
studies.
(c) Perform at a satisfactory level in a „hot-case‟ (live) exam
(d) Complete a short on-line MCQ exam (CICM website)
… the indications seem pretty clear
Indications For Transthoracic Echocardiography in the
Critically Ill Patient
1. Haemodynamically unstable patient:
- Assessment of ventricular contractility
- Identification of major valvular abnormalities
- Assessment of preload
- Assessment of left ventricular diastolic function
- Initial assessment for large intracardiac shunts
2. Unexplained respiratory failure
3. Left ventricular failure
Committee on
Echocardiography in Intensive
Care, ANZICS 2007
… the indications seem pretty clear
Indications For Transthoracic Echocardiography in the
Critically Ill Patient
4. Right heart failure/pulmonary hypertension
5. Suspected valvular disease
6. Sepsis of unknown origin - initial assessment for features of
endocarditis
7. Clinical features suggesting the presence of pericardial effusion
and tamponade
8. Suspected thoracic aortic pathology
9. Onset of new heart murmur.
Committee on
Echocardiography in Intensive
Care, ANZICS 2007
… the indications seem pretty clear
Indications For Trans-oesophageal Echocardiography
in the Critically Ill Patient
1. Inadequate TTE
2. Required detailed assessment of cardiac valves, interatrial and interventricular septum and great thoracic vessels (i.e. suspected aortic dissection).
3. Suspected endocarditis
4. Suspected cardioembolic events or screening for intracardiac thrombi prior to cardioversion.
5. Suspected dysfunction of the prosthetic valve
6. Assistance in interventional techniques and assessment of intracardiac devices.
7. Resuscitation
Committee on
Echocardiography in Intensive
Care, ANZICS 2007
Benefits of TTE
• Immediately available, non invasive
• Best modality for:
– LV function
– Right heart evaluation
– Effusions and tamponade
– Evaluation of aortic stenosis
Benefits of TOE
• Modality of choice for
– Endocarditis
– Evaluation of septal defects and shunts
– Ascending and descending aorta
– Intracardiac masses and thrombi esp LAA
• Also indicated if poor TTE windows due to
surgery, dressings, body habitus etc.
How ICU studies differ from the
cardiology outpatient lab … • Often supine, ventilated, unconscious patients • Other equipment can affect examination • Dynamic situation with concurrent resuscitation
underway • Often a specific question “Is there a cardiac
component to this patient‟s instability” • Repeated studies for monitoring • 24 hours a day requirement
How ICU studies differ from the
cardiology outpatient lab … • Often supine, ventilated, unconscious patients • Other equipment can affect examination • Dynamic situation with concurrent resuscitation
underway • Often a specific question “Is there a cardiac
component to this patient‟s instability” • Repeated studies for monitoring • 24 hours a day requirement
How ICU studies differ from the
cardiology outpatient lab … • Often supine, ventilated, unconscious patients • Other equipment can affect examination • Dynamic situation with concurrent resuscitation
underway • Often a specific question “Is there a cardiac
component to this patient‟s instability” • Repeated studies for monitoring • 24 hours a day requirement
All intensivists should be able to….
do a basic echo to answer the following
questions:
1. Is the heart working?
2. Is it really full or really empty?
3. Is there an acute severe valve lesion?
4. Is there a tamponade?
These are
not subtle
findings!!
„Level two‟ examination
• Let the experts worry about:
– Degrees of diastolic dysfunction
– Tissue doppler imaging
– Quantifying subtler valve lesions and
pressure gradients
– Little ASDs and PFOs and other shunts
– Congenital abnormalities
Focussed Assessment
• Level 1 training for all intensivists
• A FOCUSSED examination to answer
specific questions
– Not a comprehensive examination, and should
not be thought of as such
– Analagous to FAST in trauma
2nd Singapore-ANZICS Intensive Care Forum 2013
12 – 14 July 2013 Max Atria, Singapore Expo
The RACE examination
• Focussed 2D examination
– Cardiac windows
– Basic lung ultrasound
– Vena cava assessment
• Doppler examination de-emphasized
• Course 1 – 2 days with extensive hands
on experience
All registrars do RACE
• Focussed RACE course during orientation
period
• All RACE studies must be documented
– Standard pro-forma
• Consultant review of images off-line
1. Conservatism
• “You can‟t teach an old dog new tricks”
• “What I do now works for me”
• Practicalities – teaching a whole department
2. Turf wars with cardiology or radiology
3. Where do we get training?
4. Maintenance of skills
5. Amateurs „dabbling‟ - making mistakes
So why won‟t we all embrace
ultrasound?
Pitfalls of Level 1 Exams
• Over-interpreting findings
– Statements about preload and filling based
just on IVC collapse in ventilated (or non-
ventilated) patients
– RV function / ventricular interrelationships
• Missing important things
– Dyamic LVOT obstruction
• Not understanding one‟s limitations
A focused examination
Veillard-Baron et al, Bedside echocardiographic evaluation of hemodynamics in sepsis, Am J Resp Crit Care Med 2003 and Intensive Care Med 2006
Echocardiography as a haemodynamic monitor?
Easy
Often visual assessment of cardiac function
sufficient to guide therapy
Difficult
“It is better to be roughly right than precisely wrong.”
Mervyn King, the former governor of Bank of England
Does the patient have adequate cardiac output?
Outcome is improved with source control,
prompt and adequate fluid resuscitation
while striving to achieve early negative
fluid balance
CO monitors - PA catheter, PiCCO, LiDCO, Flowtrac,
oesophageal Doppler, etc…
if trend of haemodynamics and fluid
balance not according to expectation..
perform clinical examination, review the
chart and repeat echo
Does my patient need more fluid?
Static indices do not work
R: Responders
NR: Non-
responders
IVC collapsibility in mechanically ventilated patients
Collapsibility of 12%
in ventilated septic
shock patients,
positive and negative
predictive value 93
and 92%, respectively
for an increase in
cardiac output > 15%
Feissel et al. ICM 2004, Charron et al. COCC 2006
CI (%) = Exp Dmax – Insp Dmin
Exp Dmax
Dynamic parameters - inflow side
IVC diameter
Distensibility Index >
18% in mechanically
ventilated patients,
sensitivity and
specificity of 90 each
for an increase in
cardiac index > 15%
DI (%) = Exp Dmax – Insp Dmin
Exp Dmin
SVC Collapsibility Index
CI (%) = Exp Dmax – Insp Dmin
Exp Dmax
TOE
CI >36% fluid responsive
CI < 30 % NOT responsive
(DmaxSVC-DminSVC) / DmaxSVC
collapsibility index
(DmaxIVC-DminIVC) / DminIVC
distensibility index
Mitral E/E‟ ratio
PW Mitral Inflow TDI Lateral Mitral Annulus
Early mitral flow to mitral annular tissue Doppler velocity
Pulse pressure variation
Inspiration Expiration
Dynamic parameters - outflow side
SVV by Echo - LVOT/Aortic VTI
cut off -
12% for peak
LVOT/aortic
flow
cut off -
20% for
aortic VTi
PLR Volume
CI
SVC
collaps.
Passive leg raising and SVV variation
Positive response
Negative response
Crit Care Med 2006;34:1402
PLR induced changes in Ao VTI
Lamia et at Intens Care Med 2007
PLR induced increase in aortic VTI of 12.5% or more
predicted an increase in SV of 15% or more after volume
expansion with a sensitivity of 77% and a specificity of 100%
Pitfalls of haemodynamic
monitoring with echocardiography
1. Over-interpreting difficult imaging
– Atrial fibrillation
– Poor view of LVOT for CO determination
– IVC collapsibility
2. Intermittent views in a dynamic, rapidly
changing situation
– So keep the machine at the bedside, have
another look
3. Fluid responsiveness does not (necessarily)
mean give more fluid
Questions?