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Critical Care Echo Rounds

Haemodynamic instability

Echo Research & Practice volume 1, pages D1–D8 (2014)Cite this article

Abstract

The use of echocardiography, whilst well established in cardiology, is a relatively new concept in critical care medicine. However, in recent years echocardiography’s potential as both a diagnostic tool and a form of advanced monitoring in the critically ill patient has been increasingly recognised. In this series of Critical Care Echo Rounds, we explore the role of echocardiography in critical illness, beginning here with haemodynamic instability. We discuss the pathophysiology of the shock state, the techniques available to manage haemodynamic compromise, and the unique role which echocardiography plays in this complex process.

Case

A 69-year-old female presents to the emergency department with a fever, confusion and pain on urinating. Her blood pressure on arrival was 70/40, with heart rate of 117-bpm Despite 3-l of i.v. fluid she remained hypotensive. A central venous catheter was inserted and noradrenaline infusion commenced, and she was admitted to the intensive care unit for management of her shock state. At 6-h post admission, she was on high dose of noradrenaline (0.7-μg/kg per min) but blood pressure remained problematic. An echocardiogram was requested to better determine her haemodynamic state.

References

  1. Graham CA & Parke TRJ 2005 Critical care in the emergency department: shock and circulatory support. Emergency Medicine Journal 22 17–21. doi:10.1136/emj.2003.012450

    Article  CAS  Google Scholar 

  2. Clarke J 1743 A treatise, or reflections drawn from practice on gun-shot wounds. John Clarke: London, UK. Trans. of HF Le Dran 1737 Traité ou reflexions tirées de la pratique sur les playes d’armes à feu. Charles Osmont: Paris, France.

    Google Scholar 

  3. Ristic´ AD, Imazio M, Adler Y, Anastasakis A, Badano LP, Brucato A, Caforio AL, Dubourg O, Elliott P & Gimeno J Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases European Heart Journal 2014 [in press] doi:10.1093/eurheartj/ehu217

    Google Scholar 

  4. Mars T, Mikolavcic H, Salobir B & Podbregar M 2010 Echocardiography of isolated subacute left heart tamponade in a patient with cor pulmonale and circumferential pericardial effusion. Cardiovascular Ultrasound 14 8–27. doi:10.1186/1476-7120-8-27

    Google Scholar 

  5. Price LC, Wort SJ, Finney SJ, Marino PS & Brett SJ 2010 Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review. Critical Care 14 R169 doi:10.1186/cc9264

    Article  Google Scholar 

  6. Vieillard-Baron A, Schmitt JM, Roch Augarde R, Fellahi JL, Prin S, Page B, Beauchet A & Jardin F 2001 Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis. Critical Care Medicine 29 1551–1555. doi:10.1097/00003246-200108000-00009

    Article  CAS  Google Scholar 

  7. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK & Schiller NB 2010 Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. Journal of the American Society of Echocardiography 23 685–713. doi:10.1016/j.echo.2010.05.010

    Article  Google Scholar 

  8. Milan A, Magnino C & Veglio F 2010 Echocardiographic indexes for the non-invasive evaluation of pulmonary hemodynamics. Journal of the American Society of Echocardiography 23 225–239. doi:10.1016/j.echo.2010.01.003

    Article  Google Scholar 

  9. Abbas AE, Fortuin FD, Schiller NB, Appleton CP, Moreno CA & Lester SJ 2003 A simple method for noninvasive estimation of pulmonary vascular resistance. Journal of the American College of Cardiology 41 1021–1027. doi:10.1016/S0735-1097(02)02973-X

    Article  Google Scholar 

  10. Scapellato F, Temporelli PL, Eleuteri E, Corrà U, Imparato A & Giannuzzi P 2001 Accurate noninvasive estimation of pulmonary vascular resistance by Doppler echocardiography in patients with chronic failure heart failure. Journal of the American College of Cardiology 37 1813–1819. doi:10.1016/S0735-1097(01)01271-2

    Article  CAS  Google Scholar 

  11. Haddad F, Zamanian R, Beraud AS, Schnittger I, Feinstein J, Peterson T, Yang P, Doyle R & Rosenthal D 2009 A novel non-invasive method of estimating pulmonary vascular resistance in patients with pulmonary arterial hypertension. Journal of the American Society of Echocardiography 22 523–529. doi:10.1016/j.echo.2009.01.021

    Article  Google Scholar 

  12. Brown JM, Murtha W, Fraser J & Khoury V 2002 Dynamic left ventricular outflow tract obstruction in critically ill patients. Critical Care and Resuscitation 4 170–172.

    CAS  PubMed  Google Scholar 

  13. Panduranga P, Maddali MM, Mukhaini MK & Valliattu J 2010 Dynamic left ventricular outflow tract obstruction–complicating aortic valve replacement: a hidden malefactor revisited. Saudi Journal of Anaesthesia 4 99–101. doi:10.4103/1658-354X.65118

    Article  Google Scholar 

  14. Chockalingam A, Tejwani L, Aggarwal K & Dellsperger KC 2007 Dynamic left ventricular outflow tract obstruction in acute myocardial infarction with shock: cause, effect, and coincidence. Circulation 116 e110–e113. doi:10.1161/CIRCULATIONAHA.107.711697

    Article  Google Scholar 

  15. Michard F & Teboul JL 2002 Predicting fluid responsiveness in ICU patients. A critical analysis of the evidence. Chest 121 2000–2008. doi:10.1378/chest.121.6.2000

    Article  Google Scholar 

  16. Mandeville JC & Colebourn CL 2012 Can transthoracic echocardiography be used to predict fluid responsiveness in the critically ill patient? A systematic review. Critical Care Research and Practice 2012 Article ID 513480 doi:10.1155/2012/513480

    Article  Google Scholar 

  17. Berkenstadt H, Margalit N, Hadani M, Friedman Z, Segal E, Villa Y & Perel A 2001 Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery. Anesthesia and Analgesia 92 984–989. doi:10.1097/00000539-200104000-00034

    Article  CAS  Google Scholar 

  18. Feissel M, Michard F, Mangin I, Ruyer O, Faller JP & Teboul JL 2001 Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest 119 867–873. doi:10.1378/chest.119.3.867

    Article  CAS  Google Scholar 

  19. Muller L, Bobbia X, Toumi M, Louart G, Molinari N, Ragonnet B, Quintard H, Leone M, Zoric L, Lefrant JY et al 2012 Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Critical Care 16 R188 http://ccforum.com/content/16/5/R188 doi:10.1186/cc11672

    Article  Google Scholar 

  20. Feissel M, Michard F, Faller JP & Teboul JL 2004 The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Medicine 30 1834–1837. doi:10.1007/s00134-004-2233-5

    Article  Google Scholar 

  21. Monnet X & Teboul JL 2013 Assessment of volume responsiveness during mechanical ventilation: recent advances. Critical Care 17 217 doi:10.1186/cc12526

    Article  Google Scholar 

  22. Monnet X, Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR & Teboul JL 2006 Passive leg raising predicts fluid responsiveness in the critically ill. Critical Care Medicine 34 1402–1407. doi:10.1097/01.CCM.0000215453.11735.06

    Article  Google Scholar 

  23. Marik PE, Monnet X & Teboul JL 2011 Hemodynamic parameters to guide fluid therapy. Annals of Intensive Care 1 1 doi:10.1186/2110-5820-1-1

    Article  Google Scholar 

  24. Repessé X, Charron C & Vieillard-Baron A 2013 Evaluation of left ventricular systolic function revisited in septic shock. Critical Care 17 164 doi:10.1186/cc12755

    Article  Google Scholar 

  25. Akashi YJ, Goldstein DS, Barbaro G & Ueyama T 2008 Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation 118 2754–2762. doi:10.1161/CIRCULATIONAHA.108.767012

    Article  Google Scholar 

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Authors and Affiliations

  1. Critical Care Department, Faculty of Medicine, Alexandria University, Alazarita, Alexandria, Egypt

    Ashraf Roshdy MBBch MSc MD MRCP

  2. Imperial College London, National Heart and Lung Institute (NHLI), London, UK

    Ashraf Roshdy MBBch MSc MD MRCP & Nadia Francisco MSc

  3. University College of London Hospitals, London, UK

    Alejandro Rendon MSc & David Walker MRCP FRCA FFICM

  4. Critical Care Unit, King’s College Hospital, London, UK

    Stuart Gillon MbChB MRCP FFICM PGDip

Authors
  1. Ashraf Roshdy MBBch MSc MD MRCP
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  2. Nadia Francisco MSc
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  3. Alejandro Rendon MSc
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  4. Stuart Gillon MbChB MRCP FFICM PGDip
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  5. David Walker MRCP FRCA FFICM
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Corresponding author

Correspondence to Ashraf Roshdy MBBch MSc MD MRCP.

Additional information

PGDip in Perioperative and Critical Care Echocardiography

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Roshdy, A., Francisco, N., Rendon, A. et al. Critical Care Echo Rounds. Echo Res Pract 1, D1–D8 (2014). https://doi.org/10.1530/ERP-14-0008

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  • DOI: https://doi.org/10.1530/ERP-14-0008

Echo Research & Practice

ISSN: 2055-0464