Echocardiography in Intensive Care

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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Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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