Use of advanced echocardiography imaging techniques in the critically ill

Background: Critical care echocardiography has become standard of care in the ICU. New technologies have been developed and have shown potential clinical utility to elucidate myocardial dysfunction not seen with conventional imaging. We sought to determine the feasibility and potential clinical benefit of these techniques in common situations seen in the ICU. Hypothesis: Advanced echo techniques would be feasible in the majority of critically ill patients and have prognostic significance, clinical utility and diagnose cardiac abnormalities, potentially in a more sensitive manner than conventional techniques. Results: (a) Speckle tracking echocardiography (STE) Left ventricle and RV analysis with STE was feasibly in ~80% of patients. More dysfunction was found using STE vs conventional analysis. RV dysfunction assessed by STE held significant prognostic relevance in those with septic shock and highlighted subtle dysfunction induced by mechanical ventilation, both in animal and human studies. (b) 3D transthoracic echocardiography (3D TTE) Despite finding 3D TTE feasible in mechanically ventilated ICU patients (LV 72% and RV 55%), it lacked necessary low variability and high precision vs standard measures. (c) Myocardial contrast perfusion echocardiography (MCPE) Assessing acute coronary artery occlusion in the ICU patient is challenging. Troponin elevation, acute ECG changes, regional wall motion analysis on echo and overall clinical acumen often lack diagnostic capabilities. MCPE was found to be feasible in the critically ill and had better association predicting acute coronary artery occlusion vs clinical acumen alone. Conclusions: STE, 3D TTE and MCPE are feasible in the majority of ICU patients. STE may show dysfunction not recognised by conventional imaging. 3D TTE for volumetric analysis is likely not suitable for clinical use at this stage. MCPE may help guide interventions in acute coronary artery occlusion

Diaphragm strain imaging data_SO 9 5 2016.xls

Speckle tracking imaging analysis of diaphragm function in normal individual

Why guess when you can see? Heart function and fluid management in dengue shock

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Australian case of multisystem inflammatory syndrome in adults (MIS_A) occurs two months into 2021 SARS_CoV_2 Delta outbreak in New South Wales

We report, to our knowledge, the first Australian case of multisystem inflammatory syndrome in adults, a rare but severe systemic inflammatory syndrome occurring 4-6 weeks after COVID-19 infection. Clinicians should be aware of this syndrome in children or adults with shock, mucocutaneous and/or gastrointestinal features, even without prior symptomatic COVID-19 infection

Diabetic ketoacidosis due to fulminant type I diabetes : a rare subtype of type I diabetes leading to unusual sequelae

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes (T1D), which without treatment leads to death. Fulminant type 1 diabetes (FT1D) is a subtype characterised by a markedly rapid and almost complete destruction of pancreatic β-cells, with acute onset leading to severe metabolic derangement and commonly ICU admission. We present a case of an 18-year-old male presenting with FT1D with two rare complications of pneumomediastinum and stress-induced cardiomyopathy (SIC) with significant myocardial necrosis. We also discuss the aetiology of the pneumomediastinum; the latest thoughts on SIC: moving beyond the simple description of 'Takotsubo cardiomyopathy'; the role of troponins in critical illness; and genetic predisposition for DKA due to FT1D.7 page(s

Mitral regurgitation in the critically ill: the devil is in the detail

Abstract Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell

Pearls and pitfalls in comprehensive critical care echocardiography

Abstract Critical care echocardiography is developing rapidly with an increasing number of specialists now performing comprehensive studies using Doppler and other advanced techniques. However, this imaging can be challenging, interpretation is far from simple in the complex critically ill patient and mistakes can be easy to make. We aim to address clinically relevant areas where potential errors may occur and suggest methods to hopefully improve accuracy of imaging and interpretation

Feasibility of biventricular 3D transthoracic echocardiography in the critically ill and comparison with conventional parameters

Abstract Background Transthoracic 3D cardiac analysis is enticing in its potential simplicity and wealth of data available. It has been suggested to be accurate vs magnetic resonance imaging in relatively stable patients, but feasibility and agreement with conventional echocardiographic assessment of stroke volume (SV) have not been thoroughly assessed in critically ill patients, who are traditionally harder to image. The objectives of this study were to compare 3D transthoracic volumetric analysis vs Doppler assessment of SV (which is suggested to be accurate in the critically ill) and Simpson’s biplane assessment in a cohort typical of the intensive care unit (ICU), where accurate assessment is important: mechanically ventilated patients with a significant ventilation/perfusion (V/Q) mismatch. We hypothesised that it would be feasible but might lack agreement. Methods Patients were imaged within 24 hours of admission. Inclusion criteria were adult patients, V/Q mismatch present (defined as a ratio of arterial oxygen partial pressure to fractional inspired oxygen < 300), and mechanically ventilated with Doppler SV assessment possible. Biventricular echocardiographic volumetric analysis was performed using Siemens SC2000 along with standard Simpson’s biplane and Doppler SV assessment. 3D images were unacceptable if two segments or more were unable to be seen in two volumetric planes. 3D left ventricular (3DLV) and 3D right ventricular (3DRV) analyses were performed with the Tomtec Imaging and Siemens Acuson platforms, respectively. Results Ninety-two patients were included (83 in sinus, 9 in atrial fibrillation). 3DLV and 3DRV analyses were feasible in 72% and 55% of patients, respectively; however, they underestimated SV compared with Doppler by 2.6 ml (± 10.4) and 4.1 ml (± 15.4), respectively. Limits of agreement for 2D, 3DLV and 3DRV volumetric analysis techniques were large. Conclusions 3DLV and 3DRV volumetric analyses appear feasible (obtainable) in the majority of mechanically ventilated ICU patients. Compared with the Doppler method, 3DLV and 3DRV volumetric analyses underestimate SV. The large limits of agreement between the methods also cast doubt on their comparability. Given the scenarios in which SV analysis is required (e.g., assessment of cardiac performance), our study cautions against the use of 3D SV clinically

Calibrated cardiac output monitoring versus standard care for fluid management in the shocked ICU patient: a pilot randomised controlled trial

Abstract Background Despite the evidence for calibrated cardiac monitored devices to determine fluid responsiveness, there is minimal evidence that the use of cardiac output monitor devices leads to an overall change in IV fluid use. We sought to investigate the feasibility of performing a randomised controlled study using calibrated cardiac output monitoring devices in shocked ICU patients and whether the use of these devices led to a difference in total volume of IV fluid administered. Methods We performed a single-centre non-blinded randomised controlled study which included patients who met the clinical criteria for shock on admission to ICU. Patients were divided into two groups (cardiac output monitors or standard) by block randomisation. Patients allocated to the cardiac output monitor all received EV1000 with Volume View sets. Daily intravenous fluid administration and cumulative fluid balance was recorded for 3 days. The primary outcome assessed was the difference in daily intravenous fluid administration and cumulative fluid balance at 72 h between the two groups. We also assessed how often the clinicians used the cardiac monitor to guide fluid therapy and the different reasoning for initiating further intravenous fluids. Results Eighty patients were randomised and 37 received calibrated cardiac output monitors. We found no adverse outcomes in the use of calibrated cardiac output monitoring devices and that was feasible to perform a randomised controlled trial. There was no significant difference between the standard care group vs the cardiac monitoring group for cumulative fluid balance (2503 ± 3764 ml vs 2458 ± 3560 ml, p = 0.96). There was no significant difference between the groups for daily intravenous fluid administration on days 1, 2 or 3. In the cardiac monitored group, only 43% of the time was the EV1000 output incorporated into the decision to give further intravenous fluids. Conclusion It is feasible to perform a randomised controlled trial using calibrated cardiac output monitoring devices. In addition, there was no trend to suggest that the use of a cardiac monitors leads to lower IV fluid use in the shocked patient. Further trials will require study designs to optimise the use of a cardiac output monitor to determine the utility of these devices in the shocked patient. Trial registration ANZCTR, ACTRN12618001373268. Registered 15 August 2018—retrospectively registered