Bedside echocardiography in critically ill patients

Abstract

The echocardiography has become a vital tool in the diagnosis of critically ill patients. The use of echocardiography by intensivists has been increasing since the 1990's. This tool has become a common procedure for the cardiovascular assessment of critically ill patients, especially because it is non-invasive and can be applied in fast and guided manner at the bedside. Physicians with basic training in echocardiography, both from intensive care unit or emergency department, can assess the left ventricle function properly with good accuracy compared with assessment made by cardiologists. The change of treatment approach based on echocardiographic findings is commonly seen after examination of unstable patient. This brief review focuses on growing importance of echocardiography as an useful tool for management of critically ill patients in the intensive care setting along with the cardiac output assessment using this resource.

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einstein. 2015;13(4):644-6
MEDICAL DEVELOPMENTS
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ABSTRACT
The echocardiography has become a vital tool in the diagnosis of
critically ill patients. The use of echocardiography by intensivists has
been increasing since the 1990’s. This tool has become a common
procedure for the cardiovascular assessment of critically ill patients,
especially because it is non-invasive and can be applied in fast
and guided manner at the bedside. Physicians with basic training
in echocardiography, both from intensive care unit or emergency
department, can assess the left ventricle function properly with good
accuracy compared with assessment made by cardiologists. The
change of treatment approach based on echocardiographic findings is
commonly seen after examination of unstable patient. This brief review
focuses on growing importance of echocardiography as an useful tool
for management of critically ill patients in the intensive care setting
along with the cardiac output assessment using this resource.
Keywords: Echocardiography; Intensive care; Hemodynamics; Cardiac
output; Shock; Ventricular function
RESUMO
A ecocardiografia tem se tornado uma ferramenta fundamental
no atendimento ao paciente grave. Desde os anos 1990, o uso do
ecocardiograma por intensivistas vem aumentando progressivamente.
É cada vez mais frequente encontrarmos o ecocardiograma como parte
do arsenal diagnóstico na avaliação cardiovascular dos pacientes
graves, visto se tratar de uma ferramenta não invasiva, que pode
ser utilizada à beira do leito de maneira rápida e direcionada. Seja
na unidade de terapia intensiva ou no departamento de emergência,
médicos com mínimo treinamento em ecocardiografia são capazes de
avaliar a função do ventrículo esquerdo de maneira adequada e com
bom nível de concordância com a interpretação dos cardiologistas. Não
é incomum constatarmos alteração de conduta baseada nos achados
ecocardiográficos em avaliação realizada na abordagem inicial ao
paciente instável. Nessa breve revisão, o foco está voltado à crescente
importância ao ecocardiograma como ferramenta extremamente útil
na abordagem aos pacientes graves no ambiente da terapia intensiva,
aliado à avaliação do débito cardíaco, utilizando esse recurso.
Descritores: Ecocardiografia; Terapia intensiva; Hemodinâmica; Débito
cardíaco; Choque; Função ventricular
1 Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
Corresponding author: Eduardo Casaroto – Avenida Albert Einstein, 627/701, building A, 5th floor – Morumbi – Zip code: 05652-900 – São Paulo, SP, Brazil – Phone: (55 11) 2151-1520
E-mail: eduardo.casaroto@einstein.br
Received on: Sep 29, 2014 - Accepted on: Aug 10, 2015
DOI: 10.1590/S1679-45082015MD3271
INTRODUCTION
The echocardiography has evolved significantly over the
last years and, since 2001, this technique was included
in clinical practice for cardiac output assessment.(1)
This is non-invasive technique with a variety of benefits,
compared with other cardiovascular assessment techniques,
in terms of safety, low cost, wide availability, absence
of radiation exposure and need of using contrast.
In addition, it is an portable device, causes minimal
discomfort to the patient, shows immediate results and
does not require displacement of the patient to the
imaging department.
(1-4)
This device can assess the heart
structurally, functionally and hemodynamically,(4,5) and
its importance have been recognized by several scientific
society including the British Society of Echocardiography,
the American Society of Echocardiography and the World
Interactive Network Focused on Critical Ultrasound.(6)
The major indications for bedside echocardiography
are described in chart 1.
Chart 1. Major indications to hemodynamic echocardiography in the intensive
care unit(2,3,6-8)
Hypotension/hemodynamic instability of unknown etiology
Fluid responsiveness assessment
Evaluation of severe dysfunction of right ventricle
Identification of pericardial effusion/cardiac tamponade
Respiratory failure or hypoxemia of unknown etiology
Pulmonary embolism
Complications after cardiothoracic surgery
Echocardiogram is a tool that support diagnosis,
monitoring, management and clinical progress of
critically-ill patients,(7,8) in addition it works as therapeutic
interventions.(2,3) A number of non-cardiology specialists
Bedside echocardiography in critically ill patients
Ecocardiografia à beira leito em pacientes graves
Eduardo Casaroto1, Tatiana Mohovic1, Lilian Moreira Pinto1, Tais Rodrigues de Lara1

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Bedside echocardiography in critically ill patients
einstein. 2015;13(4):644-6
as anesthesiologist, intensivists and emergency
physician
have used brief approaches directed to
specific
findings,(2,3,8) and they achieve reasonable
accuracy including at other environments, not only in
intensive therapy settings.(9) This exam can be called
“echohemodynamic”, “point of care” echo, among other.
(8)
The examiner should be able to evaluate left and right
ventricular function, volemic status and pericardial
space as basic requirements.(5) A guided-exam for specific
problem has duration significantly shorter than complete
echocardiogram – about 6 minutes or shorter.(5) The
intensivist compared with other specialists need
more complex information, such as ventricular filling
pressure, contractility and cardiac output.(7) The fluid
responsiveness can also be evaluated, the need of
inotropic and/or vasopressor agents, and evaluate
mechanical ventilation impact.(7,10) Other assessments,
such as changes in vascular function and estimative
of pulmonary capillary wedge pressure, require more
advanced training.(5)
Basic competencies in echocardiographs for intensivists
according to Cholley et al.(11) include the ability to
differentiate the systolic function of left ventricle
(LV) in normal, moderate or severe dysfunction, right
ventricular dilatation, collapse or dilatation of inferior
vena cava, and pericardial effusion.(2)
When the main causes of interpretation mistakes
in bedside echo are analyzed, the biggest mistake is
related to non-recognition of depressed function of LV,
which is more common than interpret a normal function
of LV as abnormal.(9) In general, there is a tendency
to overestimate the function of LV.(9) In addition, less
trained individual can fail to recognize other important
causes of hemodynamic compromising, such as acute
cor pulmonale and acute valvular abnormalities.(9)
It is important to emphasize that complete
echocardiogram carried out by the adequate professional
can identify standard windows and adequate cardiac and
valve function, as well as structural data and a number
of other information.(8) Unfortunately, the possibility
of performing a echocardiography and get immediate
interpretation by a cardiologist is not always available
in the intensive care unit.(3,9)
To become an expert in echocardiography requires
adequate training to guarantee quality and reliability
for the exam. Adequate training avoid risks of
poor
interpretation, but it is still a challenge for most
of intensivists.(3,8,10) A ultrasonography exam requires
anatomical knowledge by the examiner for correct
assessment of the patient, in addition the examiner need
to have knowledge on physics for adequate operation of
the device.(4)
The intensive therapy environment entails a number
of difficulties to perform the exam: suboptimal lightning
conditions, drainages, edema, rapid oscillations in
hemodynamic status, ventilations, and difficulties related
to patients.
(4)
Chart 2 shows advantages and disadvantages
in the use of hemodynamic echocardiography in the
intensive therapy settings.
Chart 2. Advantages and disadvantages of echocardiography in intensive therapy
settings(4)
Advantages Disadvantages
Information previously obtained to
invasive monitoring
Intermittent measures
There is no need of other professional,
expect the physician who do the exam
No acquisition of all
echocardiographic windows
Real-time data Low offering of training programs
Safety and portable
Most limiting factors of the echocardiography
use are its intermittent character and its operating
system dependent.(10) Additionally there is the low
offering of practical training programs in hemodynamic
echocardiography, especially for intensivists.(5) Chart 3
shows other examples.
Chart 3. Limitations and challenges of transthoracic echocardiogram(4)
Multiple windows frequently needed
Repositioning of the patient is usually necessary
Particular characteristics of each patient can interfere in image acquisitions
Interference with monitoring devices
There are new and cheaper battery-powered devices
that are becoming more and more available, and constitute
an excellent tool to be used by the intensivists.(3,4) Some
experts also suggest that echocardiogram should be
used as an adjunctive tool for physical exam.
All intensivists should be able to perform at least
one brief examination in a shock situation with unknown
etiology. Based on all information we exposed above, to
know how to perform an echocardiography should be
considered a prerequisite for intensivists.(3,5)
CONCLUSION
Hemodynamic assessment was always one of the basics
for intensive therapy and for unstable patients at this
service. The use of ultrasonography is already well
consolidated. It has good accuracy, is a non-invasive, do

einstein. 2015;13(4):644-6
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Casaroto E, Mohovic T, Pinto LM, Lara TR
not expose the patient to radiation and can be performed
at bedside. Ultrasonography is no longer performed
only by radiologists. Anesthesiologists, intensivists and
emergency physicians also use this procedure in
daily clinical practice. Today is becoming common
to find a non-cardiology physician performing an
echocardiography focused on specific findings, especially
for diagnosis and management of critically unstable
patients. To obtain adequate images, and knowledge
about limitations and fails of echocardiography is key to
achieve an adequate performance with the equipment
in intensive care units. Although one of the limiting
factors to improve this technique application is still
the lack of adequate training programs, in the near
future training in echocardiography for intensivits and
emergency physicians will be probably part of their
education curriculum.
REFERENCES
1. Meyer S, Todd D, Wright I, Gortner L, Reynolds G. Review article: Non-
invasive assessment of cardiac output with portable continuous-wave
Doppler ultrasound. Emerg Med Australas. 2008;20(3):201-8. Review.
2. Romero-Bermejo FJ, Ruiz-Bailen M, Guerrero-De-Mier M, Lopez-Alvaro J.
Echocardiographic hemodynamic monitoring in the critically ill patient. Curr
Cardiol Rev. 2011;7(3):146-56. Review.
3. Beaulieu Y. Bedside echocardiography in the assessment of the critically ill.
Crit Care Med. 2007;35(5 Suppl):S235-49. Review.
4. Beaulieu Y, Marik PE. Bedside ultrasonography in the ICU: part 1. Chest.
2005;128(2):881-95. Review.
5. Beaulieu Y. Specific skill set and goals of focused echocardiography for critical
care clinicians. Crit Care Med. 2007;35(5 Suppl):S144-9.
6. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al. Focused
cardiac ultrasound in the emergent setting: a consensus statement of the
American Society of Echocardiography and American College of Emergency
Physicians. J Am Soc Echocardiogr. 2010;23(12):1225-30.
7. Slama M, Maizel J. Echocardiographic measurement of ventricular function.
Curr Opin Crit Care. 2006;12(3):241-8. Review.
8. Ore-Grinberg A, Talmor D, Brown SM. Focused critical care echocardiography.
Crit Care Med. 2013;41(11):2618-26. Review.
9. Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW. Assessment
of left ventricular function by intensivists using hand-held echocardiography.
Chest. 2009;135(6):1416-20.
10. Ayuela Azcarate JM, Clau Terré F, Ochagavia A, Vicho Pereira R. [Role of
echocardiography in the hemodynamic monitorization of critical patients].
Med Intensiva. 2012;36(3):220-32. Review. Spanish.
11. Cholley BP, Vieillard-Baron A, Mebazaa A. Echocardiography in the ICU:
time for widespread use! Intensive Care Med. 2006;32(1):9-10. Erratum in:
Intensive Care Med. 2006;32(4):634.