Hemodynamic Monitoring Using Echocardiography in the Critically Ill

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Bibliographic Information

The hemodynamic evaluation of patients with acute circulatory failure and respiratory failure has in the past usually been performed using invasive procedures but in recent years less invasive monitoring devices have been introduced. Hemodynamic evaluation by echocardiography is based on the integration of simple indices that can be easily acquired within a few minutes at the bedside.

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Echocardiography can be used for both the diagnosis and the management of circulatory and respiratory failure. This book provides all the essential information required by readers in order to perform optimal hemodynamic management of the critically ill based on echocardiographic guidance.

After an introductory section on basic principles, hemodynamic assessment using echocardiography is discussed in detail. The diagnosis and management of all types of circulatory and acute respiratory failure by means of echocardiography are then rigorously considered, and specific situations such as thoracic trauma and acute aortic syndrome are examined. The final section is devoted to future issues and applications.

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Skip to main content Skip to table of contents. Advertisement Hide. Front Matter Pages i-ix. Echocardiography in the Critically Ill: An Overview.

Table of contents

Pages Front Matter Pages Transesophageal Echocardiography: Principal Views. Heart—Lung Interactions in Mechanical Ventilation.

ARDS and circulatory failure

Valvular diseases especially mitral and aortic regurgitation should also be investigated as they could influence the course and severity of the lung disease and influence treatments, as for fluid requirement. Since a patent foramen ovale may worsen hypoxemia in ARDS patients, echocardiographic assessment should establish whether or not it is present, and, if so, its severity Figure 1.

Hemodynamic Monitoring Using Echocardiography in the Critically Ill - Ghent University Library

Because of positive pressure ventilation on the one hand, and the dramatic decrease in lung compliance on the other hand, ARDS patients are especially subject to wide variations of airway pressure, especially alveolar and transpulmonary pressures. Some experts have recently emphasized the pivotal role of evaluating such interactions for hemodynamic assessment of patients suffering from ARDS From a practical point of view, the absence of any PPV indicates that the circulatory system both LV and RV is not altered by the effect of mechanical ventilation.

Conversely, significant PPV mainly illustrates the effects of tidal inflation on the right ventricle and forces physicians to explore the underlying mechanisms further by performing CCE. In Figure 4 , we propose an algorithm of hemodynamic management based on the association of blood pressure monitoring and CCE. Decrease in RV preload during tidal ventilation is the consequence of the decrease in systemic venous return because of the increase in intrathoracic pressure, suggesting that the patient is fluid-responsive.

Management of fluids is still the subject of intense debate in the intensive care community. Besides the fact that hypovolemia when not corrected may promote shock and organ hypoperfusion, and is a confounder for severity evaluation as previously discussed, the main issue is identification of those fluid-responsive patients who would really benefit from more fluid, bearing in mind that positive fluid balance is associated with a worse outcome in ARDS 31 , Although it does not decrease mortality, fluid restriction improves oxygenation and lung injury score 33 , PPV can also illustrate the increase in RV afterload driven by high transpulmonary pressure.

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  5. Decreased lung compliance leads to a significant increase in transpulmonary pressure, i. In these cases, PPV, when significant, becomes a false positive for fluid responsiveness 39 and must lead to adaptation of the respiratory settings, the control of hypercapnia, or discussion of prone positioning of the patient, while more fluid expansion is not indicated or even contraindicated as it can worsen RV failure Furthermore, CCE is not performed blindly but rather because of abnormal vital signs suggesting poor organ perfusion skin mottling, elevated lactate, oliguria, and so on.

    CCE allows a paradigm shift from invasive, quantitative, and continuous hemodynamic monitoring to less invasive, qualitative, discontinuous and functional monitoring 41 , For this latter indication, CCE visualizes the improvement of RV function following prone positioning In a systematic review, Wetterslev et al.

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    According to our experience, we suggest that CCE be performed on ICU admission in ARDS patients to provide valuable information, not only to evaluate the clinical status of that moment but also to highlight clinical elements indicating previous diseases valvular disease, pre-existing chronic heart disease…. Thereafter, CCE should be periodically repeated according to the clinical course, but certainly should be done at least once a day. Although its value in ARDS is still questionable, some experts suggest that VV ECMO could represent an effective bridge to recovery in patients with very severe ARDS and to standard medical management including prone positioning in whom either hypoxemia is refractory or lung protective ventilation is no longer feasible VV ECMO could then facilitate the use of more protective ventilation by removing carbon dioxide from the blood and increasing blood oxygenation Both oxygenation and decarboxylation play a role here in unloading the right ventricle.

    It may allow the independent determination of the need for more fluid, for norepinephrine or dobutamine infusion, but also for adjustment of the mechanical ventilation settings and respiratory strategy. Since CCE is never performed blindly, intensivists should remember that it helps improve patient management and is not a goal in itself.

    CCE should always be associated with clinical and laboratory data, continuous invasive monitoring of blood pressure, and a central venous catheter in severe cases. Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    Figure 1 Visualization of an intracardiac shunt through a patent foramen ovale with agitated saline in a patient ventilated for an ARDS with transthoracic echocardiography.

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    Figure 2 Longitudinal upper esophageal view of the superior vena cava SVC , combining 2-D and M modes, showing cyclic collapse of the superior vena cava in a patient in shock, still hypovolemic with ARDS-related septic shock. ARDS, acute respiratory distress syndrome. Figure 3 Acute cor pulmonale in a patient ventilated with a lung protective approach. A Mid-esophageal view demonstrating a severe dilatation of the right ventricle, a markor of RV failure. Figure 5 This ventilated patient exhibited cyclic RV dilatation at each tidal inflation A , associated with a significant decrease in RV stroke volume B.

    Superior vena cava did not exhibit any respiratory variation. RV, right ventricle; LV, left ventricle.

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