Ebook Echocardiography for intensivists: Part 2

Part IV

Echocardiography in the ICU and OR:
Basic and Advanced Applications


Echocardiographic History,
Echocardiographic Monitoring,
and Goal-Directed, Focus-Oriented,
and Comprehensive Examination

23

Armando Sarti, Simone Cipani, and Massimo Barattini

23.1

What Kind of Examination?

Echocardiography is applied in the emergency and
ICU setting according to specific needs as follows.
1. First, ultrasonographic examination of the
patient. This assessment by transthoracic
echocardiography (TTE) or transesophageal
echocardiography (TEE) is performed systematically, according to a logical and reproducible
sequence which includes all major cardiovascular structures and measurements from all
echocardiographic views. Chronic findings,
such as hypertrophy or left-sided heart dilatation, must be distinguished from acute changes
in order to reconstruct the morphofunctional
history of the patient’s heart.
2. Further examination to reassess the patient.

This is more targeted to obtain more specific
information and is done in order to follow the
evolution of the clinical picture and the
response to drugs and general treatment over
time, including mechanical positive pressure
ventilation.
3. Focus-oriented or goal-directed clinical interrogation and assessment. This occurs any time
during the clinical course of hospitalization in
order to resolve a specific question or problem.
A focus-oriented or goal-directed examination

A. Sarti (&)
Department of Anesthesia and Intensive Care,
Santa Maria Nuova Hospital, Florence, Italy
e-mail:

is not a basic assessment, but is an examination
specifically designed to support the making of
quick decisions in relation to the diagnosis and
treatment following a logical algorithm or
predefined flowchart. This Chapter and
Chaps. 24–41 deal with many focus-oriented
and goal-directed assessments.
4. Rapid emergency examination. For very unstable patients the ultrasonographic assessment
will only concentrate on the essential information that can be obtained in a few minutes or
even seconds. Examples are the focused
assessment with sonography in trauma (FAST)
examination (see Chap. 46), designed to help in
the diagnosis of and the treatment plan for the
traumatized patient, and the focused emergency

echocardiography in life support (FEEL)
examination (see Chap. 42), used to obtain a
rapid diagnosis and an immediate intervention,
such as the administration of epinephrine, a
pericardium drainage, or a fluid bolus during
advanced life support.

23.2

Operator’s Skill

An inexperienced operator will be limited in
terms of what he/she is able to obtain and interpret and will need to seek help with any questions
or doubts. As the intensivist’s skills improve
progressively, he/she will be able to enhance his/
her ability to use diagnostic ultrasonography in
assessing and treating critically ill or injured
patients.

A. Sarti and F. L. Lorini (eds.), Echocardiography for Intensivists,
DOI: 10.1007/978-88-470-2583-7_23, Ó Springer-Verlag Italia 2012

221


222

Cholley et al. [2] have set out a pyramid for
the progressive acquisition of echocardiographic
expertise by intensivists. At the base there are

the less experienced workers, ideally all ICU
physicians, who are required to recognize:
• Large pericardial effusion.
• The diameter of the inferior vena cava and its
changes throughout the respiratory cycle.
• Right ventricular (RV) dilatation.
• An evident left ventricular (LV) dysfunction.
• Basic ultrasonographic appearance of the pleura
and lung.
At the center of the pyramid we find operators with more advanced training who are able
to:
• Detect severe valvular dysfunction.
• Measure RV (tricuspid annular plane systolic
excursion, TAPSE) and LV (fractional shortening, fractional area change, ejection fraction,
pulsed wave Doppler measurement of transmitral flow) systolic and diastolic function.
• Measure the systolic pulmonary pressure.
• Assess ‘‘fluid responsiveness’’.
• Perform thoracic echography.
At the top of the pyramid we have the skilled
operators, of which there is often just one or
only a few in each ICU, who have a substantial
‘‘background’’ in cardiology and who are able to
use and integrate all the techniques, including
Doppler echocardiography and tissue Doppler
imaging (TDI), and who can perform the full
range of echocardiographic diagnoses and
hemodynamic assessments.
In my opinion, junior intensivists should be
trained and certified in performing at least basic
heart and lung ultrasonography. The standard of

training courses and accreditation is highly variable around the world. Acceptable competency
requires both cognitive and technical knowledge
of ultrasound instrumentation, image acquisition,
and cardiopulmonary anatomy, physiology, and
pathology. Enough evidence from the literature
shows that reading a book in advance, a TTE/TEE
course involving both theoretical and practical
training, and ongoing mentoring and supervision
after the course can provide a high standard of
practice. Many scientific societies define procedural competency on the basis of a minimum

A. Sarti et al.

number of supervised echocardiographic examinations performed by the intensivist. However,
regular reaccreditation and continuous comparison with adequate standards are still required to
maintain competency. A recent international
round table of the European Society of Intensive
Care Medicine, endorsed by many other societies
[6], states that there was a 100 % agreement
among the participants that basic critical care
echocardiography and general critical care ultrasonography should be mandatory in the curriculum of ICU physicians.

23.3

First Comprehensive
Examination of the Patient

A systematic assessment implies the need for
substantial experience and mastery of most of
the echocardiographic techniques, including

B-mode, M-mode, continuous wave Doppler,
pulsed wave Doppler, color flow mapping
(CFM), and TDI. During the training phase, the
intensivist would be better off requesting the
intervention of the cardiologist, or another skilful intensivist, so as to perform the first systematic assessment in conjunction with an
experienced colleague.
First, it is advisable to review all previous
echocardiographic examinations, if available.
The comparison is useful to determine the starting point of the patient before the episode that led
him/her to the emergency department or ICU.
Currently observed findings are often very
different from those produced previously, even
recently. In fact, the ICU ultrasound assessment
is performed on patients in a critical or unstable
condition due to acute changes in arterial pressure, hypovolemia or hypervolemia, hypoxemia,
hypercapnia, mechanical ventilation, and high
levels of circulating catecholamines. This ‘‘stress
echocardiography’’ examination may thus show
latent disorders which are not visible at rest.
Echocardiography always starts from the
patient and must keep the patient at the center of
clinical reasoning. Before the echocardiography
machine is switched on, the patient’s medical
history, the physical examination, and all the


23

Echocardiographic History, Echocardiographic Monitoring, and Goal-Directed, Focus-Oriented

results of laboratory and radiographic findings
should be reviewed.
Each operator may follow his or her own
particular sequence of image acquisition, so as
not to overlook some data. With experience, as
soon as the operator places the probe on the
chest, a general idea of the patient’s heart will be
readily obtained. Nevertheless, it is better to
proceed in a systematic way and then come back
to specific views and focus on specific changes
in the light of the findings already detected.
A possible TTE sequence used by the author,
with the elements not to be overlooked, is as
follows.
• Parasternal long-axis view: examination of the
whole heart, pericardium, measurements of
LV outflow tract diameter, left atrium, aortic
valve, mitral valve, mitral subvalvular apparatus, CFM Doppler assessment of transvalvular flows and possible regurgitation, RV
outflow tract dimension and kinetc dysfunction, 329, 330
Cardiac efficiency, 368, 371
Cardiac mass, 62, 69
Cardiac murmur, 355, 357, 363
Cardiac output, 237, 241
Cardiac tamponade, 105–108, 111, 340
Cardiac tumors, 189, 191, 194, 229, 231
Cardioembolic sources, 192, 367
Cardiomyopathy, 133–139
Central vascular access devices (CVADs), 379
Cerebral vasospasm, 414
Chest pain, 297

Chest ultrasonography, 267
Chiari network, 103
Chordal rupture, 361
Chronic renal failure, 407, 408
Color Doppler, 198–200, 205, 401–403, 406, 408
Color flow Doppler, 183–185
Complications, 409
Comprehensive examination, 52
Compression ultrasound, 3
Congenital heart disease, 207
Congenital septal abnormalities, 197
Constrictive pericarditis, 106, 108, 110, 111
Contrast echocardiography, 198, 204, 321,
322, 324
Contrast media, 395
Contusions, 391
Coronary flow reserve, 247

D
Deep vein thrombosis (DVT), 385
Diastolic function, 47, 48
Dilatative, 137
Direct heart damage, 349
Doppler echocardiography, 7, 235, 236, 238, 239
Doppler shift, 8–10
Duke criteria, 177, 178
Dynamic bronchograms, 393
Dyspnea, 313, 314, 316, 319

A. Sarti and F. L. Lorini (eds.), Echocardiography for Intensivists,

DOI: 10.1007/978-88-470-2583-7, Ó Springer-Verlag Italia 2012

427


428
E
EA/EES ratio, 368, 371, 372
Echocardiographic criteria of fluid responsiveness, 254
Echocardiography, 21, 22, 38, 100–103, 122, 123, 152,
155, 158, 162–164, 328, 329, 331, 343,
345–347, 369, 371
Echo-history, 229, 230
Ejection fraction (EF), 76, 81, 367, 373
Emboli, 181, 182
Emergency medicine, 222, 313
Endocarditis, 353, 359–363
Endotracheal tube, 409, 411
Eustachian valve, 100, 104
Exploratory laparotomy, 397
External work, 368
Extravascular lung water, 313, 316

F
FAST, 397
Fibroma, 191, 192, 194
Fluid responsiveness, 258, 259, 261, 262, 265
Focused abdominal sonography for trauma, 397–399
Focus-oriented assessment, 221
Fossa ovalis, 99, 100, 103, 104

Free wall rupture, 355, 356

G
Global systolic function, 76, 79, 81
Goal-directed assessment, 221, 222
Graft function, 349
Graft patency, 247
Guidelines, 208

H
Heart failure, 279
Heart–lung interaction, 260, 263
Heart–lung interaction in mechanical ventilation, 263
Heart morphology, 51, 52
Hemodynamic instability, 275, 279, 280
Hemodynamic monitoring, 51
Hemorrhagic shock, 336
Hemothorax, 390
Heterotopic heart transplantation, 353
Hypertrophic, 133–136
Hypovolemia, 257–262, 275, 277, 280

I
ICU comprehensive echocardiographic examination, 229
Image optimization, 43
Inferior vena cava (IVC), 121
Intensive care echocardiography, 21
Intensive care unit, 21, 272, 275
Interatrial septum, 102, 103
Interstitial-alveolar syndrome, 390

Interventional procedures, 61, 71

Index
Interventricular septum shift, 92
Intracardiac shunt, 211, 215
Intracranial hypertension, 417
Ischemia, 125, 126, 129, 131
Isthmus of the aorta, 114, 118, 336
IVA, 146

K
Kidney, 401–408

L
Leaflet, 151–155, 160–163
Left atrial thrombus, 190
Left atrium, 99–103
Left ventricle, 44, 45
Left ventricular and right ventricular volumes, 62, 63
Left ventricular-arterial coupling, 367, 368, 371–373
Left ventricular diastolic function, 86, 88
Left ventricular filling pressure, 236, 237
Left ventricular function, 75, 78
Left ventricular outflow tract obstruction, 355, 358–360,
363, 364
Left ventricular rotation, 78
Left ventricular thrombus, 194
Levovist, 247
Local anesthesia, 409
Lung consolidation, 314, 315, 390, 394

Lung echography, 313, 314
Lung points, 391
Lung sonography, 216
Lung ultrasound, 270
LV end-systolic pressure-volume relation (ESPVR), 368

M
Mean gradient, 184, 185
Mechanical complications of myocardial
infarction, 355, 357
Mechanical ventilation, 93
Mechanical work, 368, 371
Metastatic cardiac tumor, 189, 191, 194
Mitral prosthesis, 185, 186
Mitral regurgitation, 126, 127, 129, 135–137, 139
Mitral surgery, 162
Mitral valve, 151, 152
M-mode, 46
Multiorgan donor, 349
Myocardial infarction, 125, 126, 130
Myocardial ischemia, 303, 308, 311, 312
Myocardial performance index, 89
Myocardial perfusion, 245, 247
Myxoma, 191, 192, 194

N
Neck study, 409
Non-compaction, 133, 137, 140

Index
Noninvasive, 413
Noninvasive hemodynamic monitoring, 370, 371

429
Right
Right
Right
Right

to left shunt, 321, 324
ventricle, 45, 49, 208, 215
ventricle failure, 279
ventricular (RV) overload, 197–199

O
Optic nerve, 417

P
PAP, 143–145
Papillary fibroelastoma, 191
Papillary muscle rupture, 127, 129, 355, 357, 358,
363, 364
Passive leg raising, 260, 261
Patent dutus arterious (PDA), 114, 120, 211
Patent forame ovale (PFO), 199, 245, 321
Pediatric echocardiogram, 205, 206
Penetrating chest trauma, 334
Percutaneous closure, 199, 204
Percutaneous tracheostomy, 409

Pericardial disease, 105
Pericardial effusion, 105–107, 109
Pericardial tamponade, 279, 280
Pericardial tumors, 111
Pericardium, 105–108, 111
Perioperative myocardial ischemia, 250
Peripherally inserted central catheter (PICC), 379
Perivalvular abscess, 181
Perivalvular leak, 162
Pleura, 313–319
Pleural effusion, 314
Pneumonia, 390
Pneumothorax, 313, 314, 319, 390
Pressure gradient, 235–237
Pressure half time, 169
Prosthetic dysfunction, 366
Pulmonary artery, 91–95
Pulmonary artery hypertension (PAH), 197, 198, 202,
204, 205
Pulmonary edema, 314–317, 319
Pulmonary embolism, 283, 297–299, 301–303, 314, 319,
385, 387, 394
Pulmonary hypertension, 95
Pulmonary valve, 171–173
Pulse contour methods (PCM), 370, 371

R
Real time 3D echocardiography, 243
Recruitment, 393
Regurgitation, 152, 153, 155–160, 162

Resolution, 3, 5–8
Respiratory failure, 271
Restrictive, 133, 138, 139
Right atrial pressure (RAP), 121, 123
Right atrium, 99, 102, 103

S
Sarcomas, 191, 193
Seldinger technique, 409
Sepsis, 327, 328, 330, 332
Septal rupture, 356
Septic shock, 275, 280, 327–329
Shunt, 197–199, 201–205
Sonography, 397
Standard TEE views, 52, 55
Stenosis, 152, 156, 162–164
Strain, 145–148
Strain rate, 145–148
Strain rate imaging, 129–131
Stroke volume, 239
Systolic anterior movement, 280
Systolic function, 46–49

T
TAPSE, 144
TDI, 145–149
TEE guidelines, 52
TEE probe, 207
Tei index, 147
The right ventricle, 91–97

Three-dimensional echocardiography, 324
Thrombosis, 386–388
Tissue Doppler, 46–49
Tissue Doppler imaging, 81–83, 88, 130
Tissue Doppler-strain and strain rate, 208
Transesophageal, 152, 162
Tranesophageal echocardiography (TEE), 51, 57,
114–117, 126, 211, 213, 214, 216, 228–233,
249, 289–292, 294, 298–300, 302, 306–309,
311, 322, 324, 333–335, 337, 338, 339,
343, 361
Transcranial Doppler, 413–415
Transesophageal three-dimensional echocardiography,
61, 69
Transthoracic, 152
Transthoracic echocardiography (TTE), 126, 127, 298,
307, 308, 322, 324
Transthoracic examination, 23
Transthoracic three-dimensional
echocardiography, 61, 67
Traumatic aortic injury, 333, 336, 337
Tricuspid valve, 171, 172
Tricuspid valve regurgitation, 284
TTE echocardiographic views, 40
Two-dimensional echocardiography, 241, 243


430
U
Ultrasound, 345, 379–382, 401, 405, 406, 409

Ultrasound contrast agents, 245
Ultrasound of the heart, 23
Ultrasound physics, 5
Unexplained hypoxemia, 321
Unstable patient, 363–365
US hemodynamic assessment, 222, 345

V
Valve diseases, 62, 66, 68
Valvular anatomy, 152

Index
Vegetations, 177–179, 181
Vena contracta, 168, 169
Ventilation, 269, 271, 273–275, 277
Ventricular elastance, 367
Ventricular septal defect (VSD), 198, 200–205

W
Wall motion abnormalities, 125
Weaning, 269, 271–273