Echocardiography in ICU

Michel Slama

Amiens

France

LEVEL 1 basic

LEVEL 2: advanced

How to use echocardiography in ICU patients

Two clinical situations Unexplained shock Unexplained respiratory failure

How to use echocardiography in ICU patients

Two clinical situations

Unexplained shock Unexplained respiratory failure

Step 1: rule out péricardial tamponnade

LEVEL 1 goal directed

Step 2 : evaluation of fluid responsiveness

Mean 211 / 195 52 %

CHEST 2002, 121:2000-8

R / NR R (%)

Calvin (Surgery 81) 20 / 8 71 % Schneider (Am Heart J 88) 13 / 5 72 % Reuse (Chest 90) 26 / 15 63 % Magder (J Crit Care 92) 17 / 16 52 % Diebel (Arch Surgery 92) 13 / 9 59 % Diebel (J Trauma 94) 26 / 39 40 % Wagner (Chest 98) 20 / 16 56 % Tavernier (Anesthesio 98) 21 / 14 60 % Magder (J Crit Care 99) 13 / 16 45 % Tousignant (A Analg 00) 16 / 24 40 % Michard (AJRCCM 00) 16 / 24 40 % Feissel (Chest 01) 10 / 9 53 %

CVP out….

D Osman Crit care med 2007

CVP out…. PAOP out…

D Osman Crit care med 2007

LEVEL 1

TTE : IVC

LEVEL 1

DIVC diameter = 22 %

Cardiac output will increase

by 18 % after fluid infusion

expiration inspiration

Feissel Intensive Care Med 2004

“The respiratory variation in inferior vena cava diameter as a guide to fluid therapy”

LEVEL 1

TTE or TEE : aortic Pulsed Doppler flow

Delta peak > 12% Delta VTI > 20%

LEVEL 2

12%

∆Vpeak(%)

Before fluid

infusion

4

8

12

16

20

24

28

32

36

reponders non reponders

Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock.Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Chest 2001; 119:867-873

-15

0

15

30

45

60

75

5 10 15 20 25 30 35

r2 = 0.83p < 0.001

Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock.Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Chest 2001; 119:867-873

Vpeak (%) before fluid infusion

Increase in CO afterFluid infusion

(%)

Step 3 : evaluation of LV systolic function

LV function

Ejection fractionCardiac output

Left ventricular filling pressure

Shortening Fraction

Shortening Fraction

of LV Area

Ejection Fraction

Systolic

Function

LEVEL 1

NB Shiller, Heart, 1996;75:17-26

Estimated and measured EF

LEVEL 1

TTE : Ejection fraction

Septic shock J1 Septic shock J7

Pouleur, Am J Cardiol, 1983;52:813-21

Influence of afterload on EF

HT, AS

Septic

Shock

How to perform echocardiographic examination in shocked patient?

Cardiac output TTE:

LEVEL 2

How to perform echocardiographic examination in shocked patient?

Cardiac output TTE: LEVEL 2

E/E’ ratio predicts PAOP

LEVEL 2

Combes A Int Care Med 2004

E/Ea

ICU, mechanical ventilationLEVEL 2: advanced

Step 4 : assessment of right ventricular function

No dilatation: RVDA/LVDA< 0.6

Moderate Dilation: RVDA/LVDA 0.6 - 1

Severe dilation: RVDA/LVDA > 1Jardin Chest 1997

DILATION VD

LEVEL 1

RV function

TAPSE TDI

LEVEL 2

Evaluation of pulmonary arterial pressures

Tricuspid regurgitation

Pulmonary regurgitation

LEVEL 2

Septic Shock

Cardiac failure?

No

Acute circulatory failure

Yes

No

Consider circulatory assistance

Yes

LV RV

Fluid responsiveness?

Fluid loading

Vasopressors

Inotropes Vasopressors*

Figure 5.1-2

*

LEVEL 1

Cardiogenic shock with pulmonary edema

Yes

Acute circulatory failure & pulmonary venous congestion (elevated LV filling pressures)

No

LV systolic dysfunction?

LV volume overload

• Extensive (anterior) AMI• Mechanical

complications• Small AMI on previously

compromised LV function

Cardiogenic shock

Acute myocardial infarction (AMI)?

NoYes

• Non ischemic cardiomyopathy

• Fulminant myocarditis• Myocardial contusion,

intoxication by cardiac depressant drugs…

• Acute (severe) valvular regurgitation

• Valvular prosthesis dysfunction

• Volume overload (renal failure)

LEVEL 1

Yes

Acute circulatory failure & pulmonary venous congestion (elevated LV filling pressures)

No

LV systolic dysfunction?

LV volume overload

• Extensive (anterior) AMI• Mechanical

complications• Small AMI on previously

compromised LV function

Cardiogenic shock

Acute myocardial infarction (AMI)?

NoYes

• Non ischemic cardiomyopathy

• Fulminant myocarditis• Myocardial contusion,

intoxication by cardiac depressant drugs…

• Acute (severe) valvular regurgitation

• Valvular prosthesis dysfunction

• Volume overload (renal failure)

Figure 5.1-3LEVEL 1

Yes

Acute circulatory failure & pulmonary venous congestion (elevated LV filling pressures)

No

LV systolic dysfunction?

LV volume overload

• Extensive (anterior) AMI• Mechanical

complications• Small AMI on previously

compromised LV function

Cardiogenic shock

Acute myocardial infarction (AMI)?

NoYes

• Non ischemic cardiomyopathy

• Fulminant myocarditis• Myocardial contusion,

intoxication by cardiac depressant drugs…

• Acute (severe) valvular regurgitation

• Valvular prosthesis dysfunction

• Volume overload (renal failure)

Figure 5.1-3LEVEL 1

Acute circulatory failure & systemic venous congestion

(elevated RV filling pressures)

RV dysfunction / dilatation

Cardiac tamponade

Relevant pulmonary hypertension?

Yes*No

Acute RV infarction • Massive pulmonary embolism

• ARDS• Biventricular

dysfunction (end-stage cardiomyopathy)**

Figure 5.1-4 LEVEL 1

Acute circulatory failure & systemic venous congestion

(elevated RV filling pressures)

RV dysfunction / dilatation

Cardiac tamponade

Relevant pulmonary hypertension?

Yes*No

Acute RV infarction • Massive pulmonary embolism

• ARDS• Biventricular

dysfunction (end-stage cardiomyopathy)**

Figure 5.1-4 LEVEL 1

How to use echocardiography in ICU patients

Two clinical situations Unexplained shock

Unexplained respiratory failure

Respiratory failure

Two differents clinical situations : Respiratory distress with

pulmonary edema : problem is to distinghish hemodynamic pulmonary edema and ARDS or bilateral pneumonia

Severe hypoxemia without pulmonary edema: COPD, PE or intra cardiac or pulmonary shunt

« White chest X-ray »

« Black chest X-ray »

Pulmonary edema?

Question 1: is the pulmonary wedge pressure high?

Question 2: which is the cause of this pulmonary edema?

Pulmonary edema?

Question 1: is the pulmonary wedge pressure high?

PAOP is pressure into a large pulmonary vein

PAOP

Pulmonary artery Pulmonary Vein

capillairiE

s

PAOP

Non invasive PAOP?

Mitral flow

Parameters that evaluate LV

relaxation preload independent

E/Ea ratio

LEVEL 2: advanced

Combes A Int Care Med 2004

E/Ea

ICU, mechanical ventilationLEVEL 2: advanced

Pulmonary edema?

Question 2: which is the cause of this pulmonary edema?

Evaluation of systolic function

Cause of pulmonary edema

Left ventricular systolic function

Normal Decreased

Diastolic dysfunctionValvular regurgitation

or stenosis

Pulmonary edema

Left ventricular volume (ml)

En

d d

iast

oli

c le

ft v

entr

icu

lar

pre

ssu

re (

mm

Hg

)

Cause of pulmonary edema

Left ventricular systolic function

Normal Decreased

Diastolic dysfunctionValvular regurgitation

or stenosis

Ischemic or non ischemic

cardiomyopathy

Pulmonary edema and normal PAOP : ARDS bilateral

pneumoniae

Respiratory failure

Two differents clinical situation : Respiratory distress

syndrom with pulmonary edema : problem is to distinghish between hemodynamic pulmonary edema and ARDS

Severe hypoxemia without pulmonary edema: COPD (other) or PE or intra cardiac or pulmonary shunt

Pulmonary embolism Echocardiography : ACP with RV dilation,

paradoxical septum mouvement and PAH. Venous Doppler CT Scan

Intra pulmonary shunt and Patent foramen ovale

Respiratory failure with pulmonary edema

PAOP

Elevated Normal

LV systolic dysfunction Normal systolic function ARDS, pneumonia

Valvular pathology

Diastolic dysfunction

Ischemic CM

Non ischemic CM

Respiratory failure without pulmonary edema

Contrast

Positive Negative

PFO Intra pulmonary shunt Pulmonary cause (COPD)

Case presentation