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Home | CCC | Echocardiography in Intensive Care

Echocardiography in Intensive Care

by Dr Chris Nickson, last update April 24, 2019

OVERVIEW

Echocardiography in Intensive Care allows direct visualisation of the heart, vessels and pleura

INDICATIONS

Assessment of:

  • preload
  • ventricular function
  • afterload
  • valvular function
  • aortic dissection
  • pericardial disease

American College of Cardiology Guidelines for ECHO in the Critically Ill

Category I (useful and effective)

  • haemodynamically instability
  • suspected aortic dissection or aortic injury
  • multiple trauma
  • chest trauma

Category II (may be beneficial)

  • cardiac output monitoring

Category III (unlikely to benefit and may cause harm)

  • the haemodynamically stable with no abnormal findings or cardiac disease

ARGUMENTS FOR

  • can obtain adequate TTE image in most mechanically ventilated patients
  • information gathered can change management
  • intensivists more readily available and can perform repeated examinations
  • cardiologists not used to assessment of the critically ill (effect of therapeutic interventions, inotropes, fluid therapy, IABP)
  • saving images allows review, audit, governance and quality control.

ARGUMENTS AGAINST

  • steep learning curve (written assessment + a log book of 250 ECHO’s recommended by British Society of Echocardiography)
  • requires structured training (just picking up probe can mean drawing wrong conclusions)
  • cardiologists provide more comprehensive assessment

TYPES

(1) Trans-thoracic echo (TTE)

Advantages

  • quick, easy
  • non-invasive
  • no contraindications
  • no morbidity or mortality
  • useful in seeing LV clot and pericardial effusion

Disadvantages

  • limited windows in ventilated
  • limited usefulness in endocarditis

(2) Transoesophageal echo (TOE)

Advantages

  • minimal morbidity and mortality
  • excellent images
  • good in ventilated patients
  • required in endocarditis and LA clot diagnosis
  • very useful for pericardial effusion and LV function
  • correlates well with PA catheter
  • less invasive than PA catheter
  • safe with diathermy

Disadvantages

  • take more time
  • requires sedation
  • oesophageal pathology = contraindication
  • bacteraemia
  • ulcers
  • aspiration

CONCLUSION

  • ECHO allows improved assessment and management of unstable, critically ill patients
  • essential tool for category I indications
  • continued cardiology input essential to maintain safety

References and Links

  • Briggs, J et al (2010) “Should echocardiography become a core skill for intensivists?” British Journal of Hospital Medicine, Vol 72(1) page 58

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About Dr Chris Nickson

An oslerphile emergency physician and intensivist suffering from a bad case of knowledge dipsosis. Key areas of interest include: the ED-ICU interface, toxicology, simulation and the free open-access meducation (FOAM) revolution. @Twitter | INTENSIVE| SMACC

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