Echocardiography for Hemodynamic Monitoring 2015
Brussels, Belgium, November 2015
Comprehensive summary
An International group of experts came together in Brussels for the hemodynamic monitoring using Echocardiography in the intensive care unit (ICU) course. Echocardiographic evaluation of patients in shock states constitutes a new field of research for both intensivists and critical care cardiologists. Here, a comprehensive review and photos of key lectures.
Prof. Paul May(New York, USA), Fluid responsiveness. "In New York, we keep it simple"
Many techniques exists to evaluate fluid responsiveness ( RVEDV less than 90 ml/m2 ; LVEDA of less than 10cm2 or a LVEDA index (LVEDA / BSA)) of less than 5.5cm2/m2 ; LVOT VTI variation (peak systolic velocity > 13%), variations of IVC ( 1 cm caudal from its junction with the hepatic vein)) >12%, variations of SVC (>36%), kissing papillar muscle sign, Passive leg elevation to 45° induced increase in LVOT VTI by > 12.5% (500ml over 15minutes) that may indicate significant hypovolaemia. However, many of these or bound to intrinsic problems (passive MV) and thus a combination or trends of individual values is preferred to evaluate fluid responsiveness. The "mini" (100 ml of crystalloid) fluid challenge and changes in LVOT VTI could be an interesting option.
Prof Daniel DeBacker (Brussels, Belgium), septic cardiomyopathy. "The use of ECMO for cardiac failure after septic shock is very rare"
Septic cardiomyopathy is a complication of patients with severe sepsis that has no definitive diagnostic criteria or pathophysiological hallmarks. We may say that it is a cardiac complication that, if the patients survives, is normally completely reversible. Also, it is present in up to 2/3 of patients and comprises a systolic and diastolic dysfunction of the right and left ventricle. The measurement of an EF < 45% (with no prior cardiac dysfunction) along with clinical and biomarkers are proposed as diagnostic criteria. However, patients with normal EF can have low cardiac index, and, inversely, patients with low EF may have normal CI. Echocardiographic evaluation may also help to distinguish other complications such as endocarditis, cardiac valve destruction with secondary mitral or aortic regurgitation.
Prof. Antoine Vieillard-Baron, Paris, France: Right ventricular failure ."Right ventricular breathing"
It is clear now that the higher the tidal volume (Vt), the higher the risk of acute for pulmonate (ACP). Individualized mechanical ventilation thresholds should target low driving pressures (DP 17 cmH20) and avoid hypercapnia (recruitment?). Open lung strategies reduce pulmonary vascular resistance (PVR) and aid the right ventricle. Echocardiographic anomalies related to right ventricular failure include dilation as a first phenomenon ( RVEDV/LVEDV > 0.6, lost of triangular shape, RV apex higher than LV apex), then doppler abnormalities (RV S´ wave < 10 cm/s, TAPSE < 12 mm) and finally septal bowing to the LV). Evaluation of the RV echocardiographic characteristics may help to set up the mechanical ventilation parameters in patients with ARDS or RV failure due to RV myocardial infarction.
Prof. Anthony McLean. The intensivist’s point of view. "We should take ICU-Echo to the next level"
On a personal note, i think that consolidation of ICU-echocardiography as a speciality is necessary. Many societies world-wide have validated Intensivist-operated echocardiographic evaluation of cardiac parameters that may aid in the hemodynamic management. For the to be possible, a echo machine is required in every ICU. Second, proper training and evaluation of skills is necessary to maintain competence. Lastly, a fast field of research is open thanks to the introduction of echo-labs and newer technology able to reduce inter-operator variability (thanks to automatization) and improve imagine (e.g.contrasts).
