Feature

Advanced Hemodynamic and Cardiopulmonary Ultrasound for Critically Ill Patients in the Emergency Department

Emergency Medicine. 2018 January;50(1):17-34 | 10.12788/emed.2018.0078

References

1. Kanji HD, McCallum J, Sirounis D, MacRedmond R, Moss R, Boyd JH. Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes. J Crit Care. 2014;29(5):700-705. doi:10.1016/j.jcrc.2014.04.008.

2. Raja AS, Jacobus CH. How accurate is ultrasonography for excluding pneumothorax? Ann Emerg Med. 2013;61(2):207-208. doi:10.1016/j.annemergmed.2012.07.005.

3. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and analysis. Chest. 2012;141(3):703-708. doi:10.1378/chest.11-0131.

4. Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005;12(9):844-849. doi:10.1197/j.aem.2005.05.005.

5. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest. 2011;139(5):1140-1147.

6. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004;100(1):9-15.

7. Xirouchaki N, Magkanas E, Vaporidi K, et al. Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med. 2011;37(9):1488-1493. doi:10.1007/s00134-011-2317-y.

8. Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care. 2014;4(1):1.

9. Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33(6):1231-1238.

10. Slater A, Goodwin M, Anderson KE, Gleeson FV. COPD can mimic the appearance of pneumothorax on thoracic ultrasound. Chest. 2006;129(3):545-550. doi:10.1378/chest.129.3.545.

11. Lichtenstein DA, Lascols N, Prin S, Mezière G. The “lung pulse”: an early ultrasound sign of complete atelectasis. [published online ahead of print October 14, 2003]. Intensive Care Med. 2003;29(12):2187-2192. doi:10.1007/s00134-003-1930-9.

12. Lichtenstein D. Fluid administration limited by lung sonography: the place of lung ultrasound in assessment of acute circulatory failure (the FALLS-protocol). Expert Rev Respir Med. 2012;6(2):155-162. doi:10.1586/ers.12.13.

13. Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med. 1998;24(12):1331-1334.

14. Dickman E, Terentiev V, Likourezos A, Derman A, Haines L. Extension of the thoracic spine sign: a new sonographic marker of pleural effusion. [published online ahead of print August 12, 2015]. J Ultrasound Med. 2015;34(9):1555-1561. doi:10.7863/ultra.15.14.06013.

15. Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJ, Liteplo A. Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. [published online ahead of print February 2, 2009]. Chest. 2009;135(6):1433-1439. doi:10.1378/chest.08-1811.

16. Lichtenstein D. Lung and Interstitial Syndrome. In: Lichtenstein D, ed. Whole Body Ultrasonography in the Critically IIl. New York, NY: Springer; 2010:151-157.

17. Lichtenstein DA, Mezière GA, Lagoueyte JF, Biderman P, Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest. 2009;136(4):1014-1020. doi:10.1378/chest.09-0001.

18. Romero-Bermejo FJ, Ruiz-Bailen M, Gil-Cebrian J, Huertos-Ranchal MJ. Sepsis-induced cardiomyopathy. Curr Cardiol Rev. 2011;7(3):163-183.

19. Sanfilippo F, Corredor C, Fletcher N, et al. Diastolic dysfunction and mortality in septic patients: a systematic review and meta-analysis. [published online ahead of print March 24, 2015]. Intensive Care Med. 2015;41(6):1004-1013. doi:10.1007/s00134-015-3748-7.

20. Randazzo MR, Snoey ER, Levitt MA, Binder K. Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med. 2003;10(9):973-977.

21. Reardon R. Cardiac. In: Ma O, Mateer J, eds. Emergency Ultrasound. 2nd ed. New York, NY: McGraw Hill Companies, Inc; 2008:114-115.

22. Martindale JL, Wakai A, Collins SP, et al. Diagnosing acute heart failure in the emergency department: a systematic review and meta-analysis. [published online ahead of print February 13, 2016]. Acad Emerg Med. 2016;23(3):223-242. doi:10.1111/acem.12878.

23. Cerqueira MD, Weissman NJ, Dilsizian V, et al; American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105(4):539-542.

24. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification. [published online ahead of print February 2, 2006]. Eur J Echocardiogr. 2006;7(2):79-108. doi:10.1016/j.euje.2005.12.014.

25. Secko MA, Lazar JM, Salciccioli LA, Stone MB. Can junior emergency physicians use E-point septal separation to accurately estimate left ventricular function in acutely dyspneic patients? [published online ahead of print November 1, 2011]. Acad Emerg Med. 2011;18(11):1223-1226. doi:10.1111/j.1553-2712.2011.01196.x.

26. Dinh VA, Ko HS, Rao R, et al. Measuring cardiac index with a focused cardiac ultrasound examination in the ED. [published online ahead of print July 12, 2012]. Am J Emerg Med. 2012;30(9):1845-1851. doi:10.1016/j.ajem.2012.03.025.

27. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355(3):251-259. doi:10.1056/NEJMoa052256.

28. Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009;22(2):107-133. doi:10.1016/j.echo.2008.11.023.

29. Ommen SR, Nishimura RA. A clinical approach to the assessment of left ventricular diastolic function by Doppler echocardiography: update 2003. Heart. 2003;89 Suppl 3:iii18-23.

30. Haddad F, Hunt SA, Rosenthal DN, Murphy DJ. Right ventricular function in cardiovascular disease, part I: anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation. 2008;117(11):1436-1448. doi:10.1161/CIRCULATIONAHA.107.653576.

31. Zochios V, Jones N. Acute right heart syndrome in the critically ill patient. Heart Lung Vessel. 2014;6(3):157-170.

32. Mekontso Dessap A, Boissier F, Charron C, et al. Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. [published online ahead of print December 9, 2015]. Intensive Care Med. 2016;42(5):862-870. doi:10.1007/s00134-015-4141-2.

33. Jardin F, Gueret P, Dubourg O, Farcot JC, Margairaz A, Bourdarias JP. Two-dimensional echocardiographic evaluation of right ventricular size and contractility in acute respiratory failure. Crit Care Med. 1985;13(11):952-956.

34. Dalabih M, Rischard F, Mosier JM. What’s new: the management of acute right ventricular decompensation of chronic pulmonary hypertension. [published online ahead of print September 3, 2014]. Intensive Care Med. 2014;40(12):1930-1933. doi:10.1007/s00134-014-3459-5.

35. Brennan JM, Blair JE, Goonewardena S, et al. Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr. 2007;20(7):857-861. doi:10.1016/j.echo.2007.01.005.

36. Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure. Circulation. 2008;117(13):1717-1731. doi:10.1161/CIRCULATIONAHA.107.653584.

37. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469-473.

38. Gajanana D, Seetha Rammohan H, Alli O, et al. Tricuspid annular plane systolic excursion and its association with mortality in critically ill patients. [published online ahead of print March 1, 2015]. Echocardiography. 2015;32(8):1222-1227. doi:10.1111/echo.12926.

39. Rudski LG, Lai WW, Afilalo J, et al. 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. J Am Soc Echocardiogr. 2010;23(7):685-713; quiz 786-788. doi:10.1016/j.echo.2010.05.010.

40. Vogel M, Schmidt MR, Kristiansen SB, et al. Validation of myocardial acceleration during isovolumic contraction as a novel noninvasive index of right ventricular contractility: comparison with ventricular pressure-volume relations in an animal model. Circulation. 2002;105(14):1693-1699.

41. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377. doi:10.1056/NEJMoa010307.

42. Peake SL, Delaney A, Bailey M, et al; ARISE Investigators, ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. [published online ahead of print October 1, 2014]. N Engl J Med. 2014;371(16):1496-1506. doi:10.1056/NEJMoa1404380.

43. Yealy DM, Kellum JA, Huang DT, et al; ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. [published online ahead of print March 18, 2014]. N Engl J Med. 2014;370(18):1683-1693. doi:10.1056/NEJMoa1401602.

44. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. [published online ahead of print March 17, 2015]. N Engl J Med. 2015;372(14):1301-1311. doi:10.1056/NEJMoa1500896.

45. Marik PE, Lemson J. Fluid responsiveness: an evolution of our understanding. [published online ahead of print February 16, 2014]. Br J Anaesth. 2014;112(4):617-620. doi:10.1093/bja/aet590.

46. Marik PE. Fluid Responsiveness and the Six Guiding Principles of Fluid Resuscitation. Crit Care Med. 2016;44(10):1920-1922. doi:10.1097/CCM.0000000000001483.

47. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39(2):259-265. doi:10.1097/CCM.0b013e3181feeb15.

48. Wiedemann HP, Wheeler AP, Bernard GR, et al; National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. [published online ahead of print May 21, 2006]. N Engl J Med. 2006;354(24):2564-2575. doi:10.1056/NEJMoa062200.

49. McGee S, Abernethy WB 3rd, Simel DL. The rational clinical examination. Is this patient hypovolemic? JAMA. 1999;281(11):1022-1029.

50. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41(7):1774-1781. doi:10.1097/CCM.0b013e31828a25fd.

51. Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007;35(1):64-68. doi:10.1097/01.CCM.0000249851.94101.4F.

52. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37(9):2642-2647. doi:10.1097/CCM.0b013e3181a590da.

53. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest. 2002;121(6):2000-2008.

54. Feissel M, Michard F, Faller JP, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. [published online ahead of print March 25, 2004]. Intensive Care Med. 2004;30(9):1834-1837. doi:10.1007/s00134-004-2233-5.

55. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172-178. doi:10.1378/chest.07-2331.

56. Nagdev AD, Merchant RC, Tirado-Gonzalez A, Sisson CA, Murphy MC. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. [published online ahead of print June 25, 2009]. Ann Emerg Med. 2010;55(3):290-295. doi:10.1016/j.annemergmed.2009.04.021.

57. Wallace DJ, Allison M, Stone MB. Inferior vena cava percentage collapse during respiration is affected by the sampling location: an ultrasound study in healthy volunteers. [published online ahead of print December 9, 2009]. Acad Emerg Med. 2010;17(1):96-99. doi:10.1111/j.1553-2712.2009.00627.x.

58. Blehar DJ, Resop D, Chin B, Dayno M, Gaspari R. Inferior vena cava displacement during respirophasic ultrasound imaging. Crit Ultrasound J. 2012;4(1):18. doi:10.1186/2036-7902-4-18.

59. Funk DJ, Jacobsohn E, Kumar A. The role of venous return in critical illness and shock-part I: physiology. Crit Care Med. 2013;41(1):255-262. doi:10.1097/CCM.0b013e3182772ab6.

60. Lansdorp B, Hofhuizen C, van Lavieren M, et al. Mechanical ventilation-induced intrathoracic pressure distribution and heart-lung interactions*. Crit Care Med. 2014;42(9):1983-1990. doi:10.1097/CCM.0000000000000345.

61. Barbier C, Loubières Y, Schmit C, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. [published online ahead of print March 18, 2004]. Intensive Care Med. 2004;30(9):1740-1746. doi:10.1007/s00134-004-2259-8.

62. Machare-Delgado E, Decaro M, Marik PE. Inferior vena cava variation compared to pulse contour analysis as predictors of fluid responsiveness: a prospective cohort study. J Intensive Care Med. 2011;26(2):116-124. doi:10.1177/0885066610384192.

63. Corl K, Napoli AM, Gardiner F. Bedside sonographic measurement of the inferior vena cava caval index is a poor predictor of fluid responsiveness in emergency department patients. [published online ahead of print September 7, 2012]. Emerg Med Australas. 2012;24(5):534-539. doi:10.1111/j.1742-6723.2012.01596.x.

64. Lanspa MJ, Grissom CK, Hirshberg EL, Jones JP, Brown SM. Applying dynamic parameters to predict hemodynamic response to volume expansion in spontaneously breathing patients with septic shock. Shock. 2013;39(2):155-160. doi:10.1097/SHK.0b013e31827f1c6a.

65. Muller L, Bobbia X, Toumi M, et al. Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Crit Care. 2012;16(5):R188. doi:10.1186/cc11672.

66. de Witt B, Joshi R, Meislin H, Mosier JM. Optimizing oxygen delivery in the critically ill: assessment of volume responsiveness in the septic patient. [published online ahead of print August 1, 2014]. J Emerg Med. 2014;47(5):608-615. doi:10.1016/j.jemermed.2014.06.015.

67. Monnet X, Rienzo M, Osman D, et al. Esophageal Doppler monitoring predicts fluid responsiveness in critically ill ventilated patients. [published online ahead of print July 30, 2005]. Intensive Care Med. 2005;31(9):1195-1201. doi:10.1007/s00134-005-2731-0.

68. Slama M, Masson H, Teboul JL, et al. Monitoring of respiratory variations of aortic blood flow velocity using esophageal Doppler. [published online ahead of print March 5, 2004]. Intensive Care Med. 2004;30(6):1182-1187. doi:10.1007/s00134-004-2190-z.

69. Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest. 2001;119(3):867-873.

70. Durand P, Chevret L, Essouri S, Haas V, Devictor D. Respiratory variations in aortic blood flow predict fluid responsiveness in ventilated children. [published online ahead of print February 8, 2008]. Intensive Care Med. 2008;34(5):888-894. doi:10.1007/s00134-008-1021-z.

71. Lewis JF, Kuo LC, Nelson JG, Limacher MC, Quinones MA. Pulsed Doppler echocardiographic determination of stroke volume and cardiac output: clinical validation of two new methods using the apical window. Circulation. 1984;70(3):425-431.

72. Muller L, Toumi M, Bousquet PJ, et al. An increase in aortic blood flow after an infusion of 100 ml colloid over 1 minute can predict fluid responsiveness: the mini-fluid challenge study. Anesthesiology. 2011;115(3):541-547. doi:10.1097/ALN.0b013e318229a500.

73. Lamia B, Ochagavia A, Monnet X, Chemla D, Richard C, Teboul JL. Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity. [published online ahead of print May 17, 2007]. Intensive Care Med. 2007;33(7):1125-1132. doi:10.1007/s00134-007-0646-7.

74. Maizel J, Airapetian N, Lorne E, Tribouilloy C, Massy Z, Slama M. Diagnosis of central hypovolemia by using passive leg raising. [published online ahead of print May 17, 2007]. Intensive Care Med. 2007;33(7):1133-1138. doi:10.1007/s00134-007-0642-y.

75. Monge García MI, Gil Cano A, Díaz Monrové JC. Brachial artery peak velocity variation to predict fluid responsiveness in mechanically ventilated patients. [published online ahead of print September 3, 2009]. Crit Care. 2009;13(5):R142. doi:10.1186/cc8027.

76. Blehar DJ, Glazier S, Gaspari RJ. Correlation of corrected flow time in the carotid artery with changes in intravascular volume status. [published online ahead of print April 2, 2014]. J Crit Care. 2014;29(4):486-488. doi:10.1016/j.jcrc.2014.03.025.

77. Mackenzie DC, Khan NA, Blehar D, et al. Carotid Flow Time Changes With Volume Status in Acute Blood Loss. [published online ahead of print May 21, 2005]. Ann Emerg Med. 2015;66(3):277-282.e1. doi:10.1016/j.annemergmed.2015.04.014.

78. Stolz LA, Mosier JM, Gross AM, Douglas MJ, Blaivas M, Adhikari S. Can emergency physicians perform common carotid Doppler flow measurements to assess volume responsiveness? [published online ahead of print February 26, 2015]. West J Emerg Med. 2015;16(2):255-259. doi:10.5811/westjem.2015.1.24301.

79. Marik PE, Levitov A, Young A, Andrews L. The use of bioreactance and carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients. Chest. 2013;143(2):364-370. doi:10.1378/chest.12-1274.

In healthy individuals, the RV is a low-pressure chamber that acts as a conduit for propelling venous return into the pulmonary circulation without much effect on systemic hemodynamics. However, in critical illness, RV abnormalities can have profound effects on hemodynamics, and the efforts typically used to improve LV performance will worsen a failing RV.

While RV dysfunction is most commonly due to chronic LV disease, acute RV dysfunction is commonly encountered in critical illness, ³¹ including many septic patients with ARDS, ^32,33 PE, or decompensated chronic pulmonary hypertension. ³⁴ The examinations that follow, allow the EP to assess for the presence of RV dysfunction and to guide resuscitation appropriately to avoid the untoward hemodynamic effects of conventional resuscitation strategies in these patients.

When evaluating the RV, the clinician must determine (1) if the patient’s RV strain is due to pressure or volume overload; and (2) if the patient’s RV is responsive or nonresponsive to a preload challenge, prompting an alteration in the resuscitation plan in nonresponsive cases.

Right Ventricular Pressure/Volume Overload

While inferior vena cava (IVC) ultrasound has been shown to be a pre-heart/lung assessment of cardiopulmonary interactions that predicts volume responsiveness, the IVC is also a good predictor of right atrial (RA) pressure. ³⁵ If the IVC is dilated and lacks respiratory variation, the patient likely has an elevated RA pressure, which is most likely transmitted from an elevated RV pressure ( Figure 9a ). However, compliance of the RA, RA pressure and, by extension, IVC prediction of that RA pressure, may underestimate the degree of RV pressure or afterload.

Figure 9.

In the presence of pressure overload of the RV, septal motion will be toward the LV and flatten during systole ( Figure 9b ). Despite movement of the septum toward the LV on systole, the LV is still able to fill in diastole and maintain an adequate cardiac output (often with concomitant tachycardia). When the RV is volume-overloaded, the septum flattens on diastole, which has a more deleterious effect on cardiac output ( Figure 9c ). Due to pericardial restraint on the free wall of the LV, the LV is unable to fill during diastole and thus cardiac output drops. ^30,36 The well-known “D-sign” occurs when the RV is both pressure- and volume-overloaded, which often occurs when a hypotensive patient with a pressure-overloaded RV receives a bolus of fluid. McConnell’s sign occurs when the pressure and volume-overloaded RV has apical “blinking” caused by tethering of the shared muscle fibers with the LV. ³⁷

Right Ventricular Strain and Contractile Reserve

Figure 10.

The longitudinal contraction of the RV can be easily measured on bedside ultrasound. In the apical view, M-mode imaging through the lateral annulus of the tricuspid valve will provide a measurement of the systolic movement of the RV. Increased strain on the RV will lead to decreased tricuspid annular plane systolic excursion ( Figure 10a ).³⁸

From the same apical view, tissue Doppler at the lateral tricuspid annulus will give a tricuspid annular peak velocity, a measure of the isovolumetric contraction velocity. This measurement will provide a measure of the contractile reserve of the RV (Figure 10b). A measure of less than 10 cm/sec indicates that further volume and inotropic challenges to the RV will not be effective, and the focus should be to decrease RV afterload with pulmonary vasodilators. ^34,39,40