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Louart B, Muller L, Emond B, Boulet N, Roger C. Agreement between manual and automatic ultrasound measurement of the velocity-time integral in the left ventricular outflow tract in intensive care patients: evaluation of the AUTO-VTI® tool. J Clin Monit Comput 2024:10.1007/s10877-024-01215-5. [PMID: 39287731 DOI: 10.1007/s10877-024-01215-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 08/27/2024] [Indexed: 09/19/2024]
Abstract
Transthoracic echocardiography is widely used in intensive care unit (ICU) to manage patients with acute circulatory failure. Recently, automated ultrasound (US) measurement applications have been developed but their clinical performance has not been evaluated yet. The aim of this study was to assess the agreement between automated and manual measurements of the velocity-time integral in the left ventricular outflow tract (VTI-LVOT) using the auto-VTI® tool. This prospective, single-center, interventional study included ICU patients with acute circulatory failure. The examination involved two successive manual measurements of VTI-LVOT (mean of 3 consecutive heartbeats in regular sinus rhythm, and 5 heartbeats in irregular rhythm), followed by a measurement using auto-VTI® software. In patients receiving a fluid challenge, trending ability in detecting fluid responsiveness was also evaluated. Seventy patients were included between January 19, 2020, and September 24, 2020, at the Nîmes University Hospital. The feasibility of the auto-VTI® was 94%. The mean difference between the two methods was 11% with limits of agreement from - 19% to 42%. The proportion of agreement at the 15% difference threshold was 68% [58%; 80%]. The precision and least significant change measured for the manual measurement of VTI were 7.4 and 10.5%, respectively, and by inference for the automated method 28% and 40%. The new auto-VTI® tool, despite interesting feasibility, demonstrated an insufficient agreement with a systematic bias and an insufficient precision limiting its implementation in critically ill patients.Clinical trial registration: ClinicalTrials.gov identifier: NCT04360304.
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Affiliation(s)
- Benjamin Louart
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029, Nîmes, France.
| | - Laurent Muller
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029, Nîmes, France
| | - Baptiste Emond
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029, Nîmes, France
| | - Nicolas Boulet
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029, Nîmes, France
| | - Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029, Nîmes, France
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Spacek M, Verner M. [The EDEC curriculum-the path to advanced echocardiography in the intensive care unit]. Med Klin Intensivmed Notfmed 2024; 119:381-383. [PMID: 38165422 DOI: 10.1007/s00063-023-01101-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/01/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024]
Abstract
Good knowledge of echocardiography is essential for modern intensive care medicine. A standardized curriculum for acquiring the expertise to perform TTE and TEE is a good way to strengthen one's own diagnostic skills.The EDEC curriculum from ESICM, which has been established for years, offers a good opportunity for structural further training at the advanced level in combination with gaining a high level of professional competence.
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Affiliation(s)
- M Spacek
- Interdisziplinäre Intensivstation, Fachkrankenhaus der Klinik Bavaria Kreischa/Zscheckwitz, Zscheckwitz 1-3, 01731, Kreischa, Deutschland.
| | - M Verner
- Interdisziplinäre Intensivstation, Fachkrankenhaus der Klinik Bavaria Kreischa/Zscheckwitz, Zscheckwitz 1-3, 01731, Kreischa, Deutschland
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3
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Messina A, Chew MS, Poole D, Calabrò L, De Backer D, Donadello K, Hernandez G, Hamzaoui O, Jozwiak M, Lai C, Malbrain MLNG, Mallat J, Myatra SN, Muller L, Ospina-Tascon G, Pinsky MR, Preau S, Saugel B, Teboul JL, Cecconi M, Monnet X. Consistency of data reporting in fluid responsiveness studies in the critically ill setting: the CODEFIRE consensus from the Cardiovascular Dynamic section of the European Society of Intensive Care Medicine. Intensive Care Med 2024; 50:548-560. [PMID: 38483559 DOI: 10.1007/s00134-024-07344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE To provide consensus recommendations regarding hemodynamic data reporting in studies investigating fluid responsiveness and fluid challenge (FC) use in the intensive care unit (ICU). METHODS The Executive Committee of the European Society of Intensive Care Medicine (ESICM) commissioned and supervised the project. A panel of 18 international experts and a methodologist identified main domains and items from a systematic literature, plus 2 ancillary domains. A three-step Delphi process based on an iterative approach was used to obtain the final consensus. In the Delphi 1 and 2, the items were selected with strong (≥ 80% of votes) or week agreement (70-80% of votes), while the Delphi 3 generated recommended (≥ 90% of votes) or suggested (80-90% of votes) items (RI and SI, respectively). RESULTS We identified 5 main domains initially including 117 items and the consensus finally resulted in 52 recommendations or suggestions: 18 RIs and 2 SIs statements were obtained for the domain "ICU admission", 11 RIs and 1 SI for the domain "mechanical ventilation", 5 RIs for the domain "reason for giving a FC", 8 RIs for the domain pre- and post-FC "hemodynamic data", and 7 RIs for the domain "pre-FC infused drugs". We had no consensus on the use of echocardiography, strong agreement regarding the volume (4 ml/kg) and the reference variable (cardiac output), while weak on administration rate (within 10 min) of FC in this setting. CONCLUSION This consensus found 5 main domains and provided 52 recommendations for data reporting in studies investigating fluid responsiveness in ICU patients.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy.
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy.
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniele Poole
- Anesthesia and Intensive Care Operative Unit, S. Martino Hospital, Belluno, Italy
| | - Lorenzo Calabrò
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynecology and Paediatrics, University of Verona, Via Dell'artigliere 8, 37129, Verona, Italy
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Olfa Hamzaoui
- Service de Médecine Intensive Réanimation Polyvalente, Robert Debré Hospital, University Hospitals of Reims, Unité HERVI « Hémostase et Remodelage Vasculaire Post-Ischémie » - EA 3801, University of Reims, Reims, France
| | - Mathieu Jozwiak
- Centre Hospitalier Universitaire L'Archet 1, Service de Médecine Intensive Réanimation, Nice, France
- Equipe 2 CARRES, UR2CA Unité de Recherche Clinique Université Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Christopher Lai
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Sheyla Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Laurent Muller
- Department of Anaesthesia, Critical Care and Emergency Medicine, Nîmes University Hospital, Place du Professeur Debré, 30029, Nîmes, France
- Hôpital universitaire Carémeau, University of Montpellier (MUSE), Nîmes, France
| | - Gustavo Ospina-Tascon
- Department of Intensive Care, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sebastian Preau
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000, Lille, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jean-Louis Teboul
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy
| | - Xavier Monnet
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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Zarama V, Arango-Granados MC, Manzano-Nunez R, Sheppard JP, Roberts N, Plüddemann A. The diagnostic accuracy of cardiac ultrasound for acute myocardial ischemia in the emergency department: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2024; 32:19. [PMID: 38468316 PMCID: PMC10926567 DOI: 10.1186/s13049-024-01192-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 02/29/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Chest pain is responsible for millions of visits to the emergency department (ED) annually. Cardiac ultrasound can detect ischemic changes, but varying accuracy estimates have been reported in previous studies. We synthetized the available evidence to yield more precise estimates of the accuracy of cardiac ultrasound for acute myocardial ischemia in patients with chest pain in the ED and to assess the effect of different clinical characteristics on test accuracy. METHODS A systematic search for studies assessing the diagnostic accuracy of cardiac ultrasound for myocardial ischemia in the ED was conducted in MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Web of Science, two trial registries and supplementary methods, from inception to December 6th, 2022. Prospective cohort, cross-sectional, case-control studies and randomized controlled trials (RCTs) that included data on diagnostic accuracy were included. Risk of bias was assessed with the QUADAS-2 tool and a bivariate hierarchical model was used for meta-analysis with paired Forest and SROC plots used to present the results. Subgroup analyses was conducted on clinically relevant factors. RESULTS Twenty-nine studies were included, with 5043 patients. The overall summary sensitivity was 79.3% (95%CI 69.0-86.8%) and specificity was 87.3% (95%CI 79.9-92.2%), with substantial heterogeneity. Subgroup analyses showed increased sensitivity in studies where ultrasound was conducted at ED admission and increased specificity in studies that excluded patients with previous heart disease, when the target condition was acute coronary syndrome, or when final chart review was used as the reference standard. There was very low certainty in the results based on serious risk of bias and indirectness in most studies. CONCLUSIONS Cardiac ultrasound may have a potential role in the diagnostic pathway of myocardial ischemia in the ED; however, a pooled accuracy must be interpreted cautiously given substantial heterogeneity and that important patient and test characteristics affect its diagnostic performance. PROTOCOL REGISTRATION PROSPERO (CRD42023392058).
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Affiliation(s)
- Virginia Zarama
- Facultad de Ciencias de la Salud, Universidad ICESI, Cali, Colombia.
- Department of Emergency Medicine, Fundación Valle del Lili, Carrera 98 # 18-49, 760032, Cali, Colombia.
- Nuffield Department of Primary Care Health Sciences and the Department for Continuing Education, University of Oxford, Oxford, Oxfordshire, UK.
| | - María Camila Arango-Granados
- Facultad de Ciencias de la Salud, Universidad ICESI, Cali, Colombia
- Department of Emergency Medicine, Fundación Valle del Lili, Carrera 98 # 18-49, 760032, Cali, Colombia
| | | | - James P Sheppard
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxfordshire, UK
| | - Annette Plüddemann
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
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5
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De Carvalho H, Godiveaux N, Javaudin F, Le Bastard Q, Kuczer V, Pes P, Montassier E, Le Conte P. Impact of Different Training Methods on Daily Use of Point-of-Care Ultrasound: Survey on 515 Physicians. Ultrasound Q 2024; 40:46-50. [PMID: 37756253 DOI: 10.1097/ruq.0000000000000660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
ABSTRACT Point-of-care ultrasound (POCUS) curriculum varies among countries. However, the length of training required for physicians is still under debate. We investigated the impact of different training methods: short hands-on courses (STS), long academic training sessions (LTS), or both (mixed training [MTS]), for POCUS daily use and self-reported confidence overall and specific to specific clinical situations. This was a descriptive study conducted over a 3-month period through a Web-based survey designed to assess the influence of different methods of POCUS training among physicians and residents on their daily practice. The survey was sent to 1212 emergency physicians with prior POCUS training; 515 answers (42%) could be analyzed. Participants in the STS group performed POCUS less frequently than physicians in the LTS or MTS group. Daily use in the STS group was 51% versus 82% in the LTS group and 83% in the MTS group ( P < 0.01). The overall self-reported confidence in POCUS was lower in the STS group ( P < 0.01) in all studied clinical situations. There was no significant difference between LTS and MTS groups ( P > 0.05). Method of POCUS training significantly influenced POCUS daily use. Physicians who underwent long training sessions used POCUS more frequently in their routine practice and were significantly more confident in their ability to perform and interpret a POCUS examination.
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Affiliation(s)
| | | | | | | | | | - Philippe Pes
- Emergency Department, Centre Hospitalier Universitaire
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6
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Abid I, Qureshi N, Lategan N, Williams S, Shahid S. Point-of-care lung ultrasound in detecting pneumonia: A systematic review. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2024; 60:37-48. [PMID: 38299193 PMCID: PMC10830142 DOI: 10.29390/001c.92182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/09/2023] [Indexed: 02/02/2024]
Abstract
Purpose Limited evidence exists to assess the sensitivity, specificity, and accuracy of point-of-care lung ultrasound (LUS) across all age groups. This review aimed to investigate the benefits of point-of-care LUS for the early diagnosis of pneumonia compared to traditional chest X-rays (CXR) in a subgroup analysis including pediatric, adult, and geriatric populations. Material and Methods This systematic review examined systematic reviews, meta-analyses, and original research from 2017 to 2021, comparing point-of-care LUS and CXR in diagnosing pneumonia among adults, pediatrics and geriatrics. Studies lacking direct comparison or exploring diseases other than pneumonia, case reports, and those examining pneumonia secondary to COVID-19 variants were excluded. The search utilized PubMed, Google Scholar, and Cochrane databases with specific search strings. The study selection, conducted by two independent investigators, demonstrated an agreement by the Kappa index, ensuring reliable article selection. The QUADAS-2 tool assessed the selected studies for quality, highlighting risk of bias and applicability concerns across key domains. Statistical analysis using Stata Version 16 determined pooled sensitivity and specificity via a bivariate model, emphasizing LUS and CXR diagnostic capabilities. Additionally, RevMan 5.4.1 facilitated the calculation of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), offering insights into diagnostic accuracy. Results The search, conducted across PubMed, Google Scholar, and Cochrane Library databases by two independent investigators, initially identified 1045 articles. Following screening processes, 12 studies comprised a sample size of 2897. LUS demonstrated a likelihood ratio of 5.09, a specificity of 81.91%, and a sensitivity of 92.13% in detecting pneumonia in pediatric, adult, and geriatric patients, with a p-value of 0.0002 and a 95% confidence interval, indicating diagnostic accuracy ranging from 84.07% to 96.29% when compared directly to CXR. Conclusion Our review supports that LUS can play a valuable role in detecting pneumonia early with high sensitivity, specificity, and diagnostic accuracy across diverse patient demographics, including pediatric, adult, and geriatric populations. Since it overcomes most of the limitations of CXR and other diagnostic modalities, it can be utilized as a diagnostic tool for pneumonia for all age groups as it is a safe, readily available, and cost-effective modality that can be utilized in an emergency department, intensive care units, wards, and clinics by trained respiratory care professionals.
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Affiliation(s)
- Iqra Abid
- Respiratory Therapy Services Sidra Medical and Research Center
| | - Nadia Qureshi
- Alberta Health Services Respiratory Health Section, Medicine Strategic Clinical Network
| | - Nicola Lategan
- Respiratory Therapy Services Sidra Medical and Research Center
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7
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Tagle-Cornell MC, Novais BS, Wen S, Shipman JN, Mandale DR, Flom AP, Sahnan SK, Kriz LM, Alland ML, Bird CW, Naqvi TZ. Hand-Held Echocardiography by Advanced Practice Providers in Patients with Congestive Heart Failure. J Clin Med 2024; 13:312. [PMID: 38256445 PMCID: PMC10816508 DOI: 10.3390/jcm13020312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVES The performed hand-held echocardiography (HHE) was evaluated and interpreted by trained advanced practice providers (APPs) on hospitalized CHF patients for image quality and interpretation by comparing with expert echocardiographer and SE findings. BACKGROUND Congestive heart failure (CHF) is associated with increased hospital admissions and mortality. While a standard echocardiogram (SE) is the gold standard for cardiac assessment, it is not readily available. Hospitalized CHF patients require rapid assessment for expedited treatment. METHODS Over 6 months, five trained APPs performed HHE on hospitalized CHF patients and interpreted: (a) left ventricular (LV) size, (b) LV ejection fraction (LVEF), and (c) right atrial pressure (RAP). The study echocardiographer reviewed and blindly interpreted the HHE images and compared them with APPs and SE findings. Kappa statistics determined the degree of agreement between APPs and the study echocardiographer's interpretation of the HHE images and SE. RESULTS A total of 80 CHF patients (age 73 ± 14 years, 58% males; LVEF (by SE) 45 ± 19%; 36.3% body mass indexes ≥ 30 kg/m2) were enrolled. HHE interpretation by APPs had a good agreement for LVEF (kappa 0.79) with the study echocardiographer and SE (kappa 0.74) and a good agreement for RAP (kappa 0.67) with the study echocardiographer. The correlation between the absolute LVEF interpretation by the study echocardiographer on HHE and SE was r = 0.88 (p < 0.0001). CONCLUSIONS Trained APPs obtained diagnostic-quality HHE images and interpreted the LV function and RAP in CHF patients in good agreement with the study echocardiographer. LVEF by HHE correlated with LVEF by SE. Our study suggests trained APPs can use HHE to evaluate LVEF and RAP in CHF patients, leading to expedited and optimized treatment.
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Affiliation(s)
- Maria Cecilia Tagle-Cornell
- Division of Echocardiography, Department of Cardiovascular Medicine, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA; (B.S.N.); (S.W.); (J.N.S.); (D.R.M.); (A.P.F.); (S.K.S.); (L.M.K.); (M.L.A.); (C.W.B.)
| | | | | | | | | | | | | | | | | | | | - Tasneem Z. Naqvi
- Division of Echocardiography, Department of Cardiovascular Medicine, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA; (B.S.N.); (S.W.); (J.N.S.); (D.R.M.); (A.P.F.); (S.K.S.); (L.M.K.); (M.L.A.); (C.W.B.)
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8
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Loosen G, Conrad AM, Essert N, Boesing C, Hagmann M, Thiel M, Luecke T, Rocco PRM, Pelosi P, Krebs J. Preload Responsiveness in Patients With Acute Respiratory Distress Syndrome Managed With Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:53-61. [PMID: 37934718 DOI: 10.1097/mat.0000000000002054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
A restrictive fluid strategy is recommended in patients with acute respiratory distress syndrome (ARDS) managed with venovenous extracorporeal membrane oxygenation (VV ECMO). However, there are no established predictors for preload responsiveness in these patients. In 20 ARDS patients managed with VV ECMO, transesophageal echocardiography was used to repeatedly evaluate dynamic parameters of the left (velocity and stroke volume variation) and right ventricular outflow tract (velocity [respiratory variations of the maximal Doppler velocity in the truncus pulmonalis {ΔV max TP}] and velocity time integral [respiratory variation of the velocity time integral measured in the truncus pulmonalis {ΔVTI_TP}] variation in the truncus pulmonalis), the diameter variation in the superior and inferior vena cava and stroke volume variation measured by pulse contour analysis (SVV_PCA). Patients were categorized as responders and nonresponders according to an increase in stroke volume measured by echocardiography during a Passive Leg Raise Test with a cutoff value ≥10%. The final analysis includes 86 measurements. Predictive values for preload responsiveness were found for ΔV max TP (area under the curve [AUC] of 0.64), ΔVTI_TP (AUC 0.67), and SVV_PCA (AUC 0.74). In conclusion, SVV_PCA and, to a lesser extent, ΔV max TP and ΔVTI_TP are the most accurate parameters to predict preload responsiveness in ARDS patients managed with VV ECMO. Transesophageal echocardiography offers no advantages over pulse contour analysis for predicting preload responsiveness and provides only intermittent monitoring and assessment.
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Affiliation(s)
- Gregor Loosen
- From the Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Alice Marguerite Conrad
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Nils Essert
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Christoph Boesing
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Michael Hagmann
- Department of Computational Linguistics, University of Heidelberg, Heidelberg, Germany
- Interdisciplinary Centre for Scientific Computing, Statistical Natural Language Processing Group, University of Heidelberg, Heidelberg, Germany
| | - Manfred Thiel
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Thomas Luecke
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Department of Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Joerg Krebs
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
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Rubino A, Peck M, Miller A, Edmiston T, Klein AA, Orme R, Sankar V, Fletcher N, O’Keeffe N, Skinner H. Focused transoesophageal TOE (fTOE): A new accreditation pathway. J Intensive Care Soc 2023; 24:419-426. [PMID: 37841296 PMCID: PMC10572472 DOI: 10.1177/17511437231173350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using transthoracic scanning protocols, such as FUSIC Heart, has empowered non-cardiologists to rapidly identify and treat the major causes of haemodynamic instability. There are, however, circumstances when a transoesphageal, rather than transthoracic approach, may be preferrable. Due to the close anatomical proximity between the oesophagus, stomach and heart, a transoesphageal echocardiogram (TOE) can potentially overcome many of the limitations encountered in patients with poor transthoracic ultrasound windows. These are typically patients with severe obesity, chest wall injuries, inability to lie in the left lateral decubitus position and those receiving high levels of positive airway pressure. In 2022, to provide all acute care practitioners with the opportunity to acquire competency in focused TOE, the Intensive Care Society (ICS) and Association of Anaesthetists (AA) launched a new accreditation pathway, known as Focused Transoesophageal Echo (fTOE). The aim of fTOE is to provide the practitioner with the necessary information to identify the aetiology of haemodynamic instability. Focused TOE can be taught in a shorter period of time than comprehensive and teaching programmes are achievable with support from cardiothoracic anaesthetists, intensivists and cardiologists. Registration for fTOE accreditation requires registration via the ICS website. Learning material include theoretical modules, clinical cases and multiple-choice questions. Fifty fTOE examinations are required for the logbook, and these must cover a range of pathology, including ventricular dysfunction, pericardial effusion, tamponade, pleural effusion and low preload. The final practical assessment may be undertaken when the supervisors deem the candidate's knowledge and skills consistent with that required for independent practice. After the practitioner has been accredited in fTOE, they must maintain knowledge and competence through relevant continuing medical education. Accreditation in fTOE represents a joint venture between the ICS and AA and is endorsed by Association of Cardiothoracic Anaesthesia and Critical care (ACTACC). The process is led by TOE experts, and represents a valuable expansion in the armamentarium of acute care practitioners to assess haemodynamically unstable patients.
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Affiliation(s)
- Antonio Rubino
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Marcus Peck
- Frimley Health NHS Foundation Trust, Frimley, UK
| | - Ashley Miller
- Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Thomas Edmiston
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Andrew A Klein
- Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Robert Orme
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Vinoth Sankar
- Liverpool University Hospitals NHS Foundation Trust, University of Liverpool, Liverpool, UK
| | | | - Niall O’Keeffe
- Manchester Royal Infirmary, University of Manchester, Manchester, UK
| | - Henry Skinner
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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10
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Lee JY, Conlon TW, Fraga MV, Bauer AJ, Soni NJ, Chen AE, Kaplan SL. Identifying commonalities in definition and governance of point-of-care ultrasound within statements from medical organizations in the United States: A scoping review for a shared understanding. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:1622-1630. [PMID: 37850556 DOI: 10.1002/jcu.23574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/19/2023] [Indexed: 10/19/2023]
Abstract
This scoping review analyzed statements from 22 medical organizations in the United States to identify commonalities in the definition and governance of point-of-care ultrasound (POCUS). A total of 41 statements were included. The review found that the most commonly used elements in defining POCUS were "focused," "bedside," and "patient care." In terms of governance, consistent requirements included specific training programs, documentation in medical records, continuous quality assurance, and standards for credentialing and privileging. These findings suggest the existence of essential commonalities that could facilitate communication and the development of standardized POCUS programs in the future.
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Affiliation(s)
- Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas W Conlon
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria V Fraga
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew J Bauer
- Division of Endocrinology and Diabetes, The Thyroid Center, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nilam J Soni
- Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Aaron E Chen
- Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Summer L Kaplan
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Harrington J, Aron J, Lashin H. The Role of Focused 2-Dimensional Echocardiography in Managing Left Ventricular Outflow Tract Obstruction Mimicking Cardiogenic Shock. J Intensive Care Med 2023; 38:897-902. [PMID: 37287244 DOI: 10.1177/08850666231180814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Left ventricular outflow tract obstruction (LVOTO) is a common cardiogenic shock (CS) mimic. We present 3 cases of patients presenting with CS following myocardial infarction, exhibiting a poor response to conventional treatment with inotropy and mechanical circulatory support. This triggered echocardiographic assessment by critical care physicians using focused 2-dimensional (2D) echocardiography. This timely assessment identified anterior mitral valve leaflet entrainment into the left ventricular outflow tract (LVOT), causing LVOTO as the underlying shock mechanism. Echocardiographic findings have led to significant changes in management. The patients underwent fluid administration, weaning from inotropy, and mechanical circulatory support explantation, leading to relief of LVOTO and improved hemodynamics. Critical care basic 2D echocardiography accreditations focus on myocardial function and pericardial effusions. Relevant societies administering these accreditations should consider adding LVOT assessment to enable timely diagnosis of this life-threatening CS mimic.
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Affiliation(s)
- Julia Harrington
- Adult Critical Care Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Jonathan Aron
- Adult Critical Care Unit, St George's Hospital, London, UK
| | - Hazem Lashin
- Adult Critical Care Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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12
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Wray TC, Gerstein N, Ball E, Hanna W, Tawil I. Seeing the heart of the problem: transesophageal echocardiography in cardiac arrest: a practical review. Int Anesthesiol Clin 2023; 61:15-21. [PMID: 37602416 DOI: 10.1097/aia.0000000000000411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Affiliation(s)
- Trenton C Wray
- Department of Emergency Medicine, Division of Adult Critical Care, The University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Neal Gerstein
- Department of Anesthesiology and Critical Care, The University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Emily Ball
- Department of Emergency Medicine, Division of Adult Critical Care, The University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Wendy Hanna
- Department of Emergency Medicine, The University of New Mexico School of Medicine. Albuquerque, New Mexico
| | - Isaac Tawil
- Department of Emergency Medicine, Division of Adult Critical Care, The University of New Mexico School of Medicine, Albuquerque, New Mexico
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13
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Ochagavía A, Fraile V, Zapata L. Introduction to the update series: update in intensive care medicine: ultrasound in the critically ill patient. Clinical applications. Med Intensiva 2023; 47:526-528. [PMID: 37634919 DOI: 10.1016/j.medine.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Ana Ochagavía
- Servicio de Medicina Intensiva, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat (Barcelona). Spain.
| | - Virginia Fraile
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega. Valladolid. Spain.
| | - Lluis Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona. Spain.
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14
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Padilla C, Ortner C, Dennis A, Zieleskiewicz L. The need for maternal critical care education, point-of-care ultrasound and critical care echocardiography in obstetric anesthesiologists training. Int J Obstet Anesth 2023; 55:103880. [PMID: 37105833 DOI: 10.1016/j.ijoa.2023.103880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/05/2023]
Abstract
Globally, the increase in medically complex obstetric patients is challenging the educational approach and clinical management of critically ill obstetric patients. This increase in medical complexity calls into question the educational paradigm in which future physicians are trained. Obstetric anesthesiologists, physician experts in the perio-perative planning and management of complex obstetric patients, represent an essential workforce in the strategies to address maternal mortality. Unfortunately, the development of peri-operative medicine and maternal critical care curricula has only received minor attention in most countries. Proposed guidelines and models highlight the existing need for tiered maternity care services in which critical care infrastructure plays a central role in the delivery of high-risk peripartum care. Therefore, the development of maternal critical care models designed to prepare obstetric anesthesiologists for the clinical challenges of a medically complex patient are warranted. Key critical care topics such as advanced ultrasonography, with the inclusion of quantitative echocardiographic assessments into obstetric anesthesiology educational curricula, will serve to better prepare physicians for the realities of an increasingly complex pregnant patient population, and further reinforce the critical care infrastructure detailed in the Levels of Maternal Care consensus. Despite an increasingly complex obstetric patient population, heterogeneity of maternal critical care practices exists across the globe, warranting standardization and further development of proposed curricula.
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Affiliation(s)
- C Padilla
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - C Ortner
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA
| | - A Dennis
- Departments of Critical Care, Obstetrics and Gynecology, and Pharmacology, University of Melbourne, Australia
| | - L Zieleskiewicz
- Département d'Anesthésie-Réanimation, Médecine Péri-opératoire, Hôpital Nord, AP-HM Marseille, France
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15
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Conrad AM, Loosen G, Boesing C, Thiel M, Luecke T, Rocco PRM, Pelosi P, Krebs J. Effects of changes in veno-venous extracorporeal membrane oxygenation blood flow on the measurement of intrathoracic blood volume and extravascular lung water index: a prospective interventional study. J Clin Monit Comput 2023; 37:599-607. [PMID: 36284041 PMCID: PMC9595580 DOI: 10.1007/s10877-022-00931-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022]
Abstract
In severe acute respiratory distress syndrome (ARDS), veno-venous extracorporeal membrane oxygenation (V-V ECMO) has been proposed as a therapeutic strategy to possibly reduce mortality. Transpulmonary thermodilution (TPTD) enables monitoring of the extravascular lung water index (EVLWI) and cardiac preload parameters such as intrathoracic blood volume index (ITBVI) in patients with ARDS, but it is not generally recommended during V-V ECMO. We hypothesized that the amount of extracorporeal blood flow (ECBF) influences the calculation of EVLWI and ITBVI due to recirculation of indicator, which affects the measurement of the mean transit time (MTt), the time between injection and passing of half the indicator, as well as downslope time (DSt), the exponential washout of the indicator. EVLWI and ITBVI were measured in 20 patients with severe ARDS managed with V-V ECMO at ECBF rates from 6 to 4 and 2 l/min with TPTD. MTt and DSt significantly decreased when ECBF was reduced, resulting in a decreased EVLWI (26.1 [22.8-33.8] ml/kg at 6 l/min ECBF vs 22.4 [15.3-31.6] ml/kg at 4 l/min ECBF, p < 0.001; and 13.2 [11.8-18.8] ml/kg at 2 l/min ECBF, p < 0.001) and increased ITBVI (840 [753-1062] ml/m2 at 6 l/min ECBF vs 886 [658-979] ml/m2 at 4 l/min ECBF, p < 0.001; and 955 [817-1140] ml/m2 at 2 l/min ECBF, p < 0.001). In patients with severe ARDS managed with V-V ECMO, increasing ECBF alters the thermodilution curve, resulting in unreliable measurements of EVLWI and ITBVI. German Clinical Trials Register (DRKS00021050). Registered 14/08/2018. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00021050.
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Affiliation(s)
- Alice Marguerite Conrad
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany
| | - Gregor Loosen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Cambridge Biomedical Campus, Cambridge, CB2 0AY UK
| | - Christoph Boesing
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany
| | - Manfred Thiel
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany
| | - Thomas Luecke
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Joerg Krebs
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany
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16
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Prager R, Bowdridge J, Pratte M, Cheng J, McInnes MDF, Arntfield R. Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review. J Intensive Care Med 2023; 38:245-272. [PMID: 35854414 PMCID: PMC9806486 DOI: 10.1177/08850666221115348] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) - lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE. METHODS MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate. RESULTS Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported. CONCLUSIONS The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.
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Affiliation(s)
- Ross Prager
- Division of Critical Care, Western University, Stn B. London, ON, Canada,Ross Prager, Critical Care Trauma Centre,
Victoria Hospital. Rm # D2-528 London Health Sciences Centre, 800 Commissioners
Rd. E, London, ON N6A 5W9, Canada.
| | - Joshua Bowdridge
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michael Pratte
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jason Cheng
- Division of Critical Care, Western University, Stn B. London, ON, Canada
| | - Matthew DF McInnes
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada, Clinical Epidemiology Program, The Ottawa Hospital Research
Institute, Ottawa, ON, Canada
| | - Robert Arntfield
- Division of Critical Care, Western University, Stn B. London, ON, Canada
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17
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Millington SJ, Mayo-Malasky H, Koenig S. Agitated Saline Contrast Injection in Patients with Severe Hypoxemia. J Intensive Care Med 2023; 38:479-486. [PMID: 36827332 PMCID: PMC10154990 DOI: 10.1177/08850666231159019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
The use of agitated saline contrast (ASC) during echocardiographic examinations is a well-established practice, most commonly performed to identify atrial septal abnormalities in the context of stroke. In the intensive care unit, this technique may be employed to identify anatomic right-to-left shunts (either intracardiac or transpulmonary) that may be contributing to hypoxemic respiratory failure. This narrative review will describe the technique of ASC injection, summarize clinical scenarios where it may be useful, and review the strengths and limitations of the tool.
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Affiliation(s)
- Scott J Millington
- Department of Critical Care, University of Ottawa/The Ottawa Hospital, Ottawa, ON Canada
| | - Henry Mayo-Malasky
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 25049Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Seth Koenig
- Department of Critical Care, Kent Hospital, Warwick, RI, USA
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18
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Valenzuela ED, Mercado P, Pairumani R, Medel JN, Petruska E, Ugalde D, Morales F, Eisen D, Araya C, Montoya J, Gonzalez A, Rovegno M, Ramirez J, Aguilera J, Hernández G, Bruhn A, Slama M, Bakker J. Cardiac function in critically ill patients with severe COVID: A prospective cross-sectional study in mechanically ventilated patients. J Crit Care 2022; 72:154166. [PMID: 36244256 PMCID: PMC9557772 DOI: 10.1016/j.jcrc.2022.154166] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/29/2022] [Accepted: 09/18/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To evaluate cardiac function in mechanically ventilated patients with COVID-19. MATERIALS AND METHODS Prospective, cross-sectional multicenter study in four university-affiliated hospitals in Chile. All consecutive patients with COVID-19 ARDS requiring mechanical ventilation admitted between April and July 2020 were included. We performed systematic transthoracic echocardiography assessing right and left ventricular function within 24 h of intubation. RESULTS 140 patients aged 57 ± 11, 29% female were included. Cardiac output was 5.1 L/min [IQR 4.5-6.2] and 86% of the patients required norepinephrine. ICU mortality was 29% (40 patients). Fifty-four patients (39%) exhibited right ventricle dilation out of whom 20 patients (14%) exhibited acute cor pulmonale (ACP). Eight out of the twenty patients with ACP exhibited pulmonary embolism (40%). Thirteen patients (9%) exhibited left ventricular systolic dysfunction (ejection fraction <45%). In the multivariate analysis acute cor pulmonale and PaO2/FiO2 ratio were independent predictors of ICU mortality. CONCLUSIONS Right ventricular dilation is highly prevalent in mechanically ventilated patients with COVID-19 ARDS. Acute cor pulmonale was associated with reduced pulmonary function and, in only 40% of patients, with co-existing pulmonary embolism. Acute cor pulmonale is an independent risk factor for ICU mortality.
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Affiliation(s)
- Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Pablo Mercado
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Ronald Pairumani
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Juan Nicolás Medel
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Edward Petruska
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Diego Ugalde
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Felipe Morales
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Daniela Eisen
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Carla Araya
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Jorge Montoya
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Alejandra Gonzalez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Ramirez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javiera Aguilera
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Michel Slama
- Medical Intensive Care Unit, CHU Sud Amiens, Amiens, France
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile,Department of intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands,Department of Pulmonary and Critical Care, New York University, NYU Langone Health, New York, USA,Department of Pulmonary and Critical Care, Columbia University Medical Center, New York, USA
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19
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Song J, Yao Y, Lin S, He Y, Zhu D, Zhong M. Feasibility and discriminatory value of tissue motion annular displacement in sepsis-induced cardiomyopathy: a single-center retrospective observational study. Crit Care 2022; 26:220. [PMID: 35851427 PMCID: PMC9295263 DOI: 10.1186/s13054-022-04095-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
There is no formal diagnostic criterion for sepsis-induced cardiomyopathy (SICM), but left ventricular ejection fraction (LVEF) < 50% was the most commonly used standard. Tissue motion annular displacement (TMAD) is a novel speckle tracking indicator to quickly assess LV longitudinal systolic function. This study aimed to evaluate the feasibility and discriminatory value of TMAD for predicting SICM, as well as prognostic value of TMAD for mortality.
Methods
We conducted a single-center retrospective observational study in patients with sepsis or septic shock who underwent echocardiography examination within the first 24 h after admission. Basic clinical information and conventional echocardiographic data, including mitral annular plane systolic excursion (MAPSE), were collected. Based on speckle tracking echocardiography (STE), global longitudinal strain (GLS) and TMAD were, respectively, performed offline. The parameters acquisition rate, inter- and intra-observer reliability, time consumed for measurement were assessed for the feasibility analysis. Areas under the receiver operating characteristic curves (AUROC) values were calculated to assess the discriminatory value of TMAD/GLS/MAPSE for predicting SICM, defined as LVEF < 50%. Kaplan–Meier survival curve analysis was performed according to the cutoff values in predicting SICM. Cox proportional hazards model was performed to determine the risk factors for 28d and in-hospital mortality.
Results
A total of 143 patients were enrolled in this study. Compared with LVEF, GLS or MAPSE, TMAD exhibited the highest parameter acquisition rate, intra- and inter-observer reliability. The mean time for offline analyses with TMAD was significantly shorter than that with LVEF or GLS (p < 0.05). According to the AUROC analysis, TMADMid presented an excellent discriminatory value for predicting SICM (AUROC > 0.9). Patients with lower TMADMid (< 9.75 mm) had significantly higher 28d and in-hospital mortality (both p < 0.05). The multivariate Cox proportional hazards model revealed that BMI and SOFA were the independent risk factors for 28d and in-hospital mortality in sepsis cases, but TMAD was not.
Conclusion
STE-based TMAD is a novel and feasible technology with promising discriminatory value for predicting SICM with LVEF < 50%.
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20
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Merdji H, Curtiaud A, Aheto A, Studer A, Harjola VP, Monnier A, Duarte K, Girerd N, Kibler M, Ait-Oufella H, Helms J, Mebazaa A, Levy B, Kimmoun A, Meziani F. Performance of Early Capillary Refill Time Measurement on Outcomes in Cardiogenic Shock: An Observational, Prospective Multicentric Study. Am J Respir Crit Care Med 2022. [DOI: 10.1164/rccm.202204-0687oc 10.1164/rccm.202204-0687oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Hamid Merdji
- Université de Strasbourg, Faculté de Médecine; Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), Unité Mixte de Recherche (UMR) 1260, Regenerative Nanomedicine, Strasbourg, France
| | - Anais Curtiaud
- Université de Strasbourg, Faculté de Médecine; Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
| | - Antoine Aheto
- Université de Strasbourg, Faculté de Médecine; Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
| | - Antoine Studer
- Université de Strasbourg, Faculté de Médecine; Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Helsinki, Finland
- Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Alexandra Monnier
- Université de Strasbourg, Faculté de Médecine; Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
| | - Kevin Duarte
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433; Medical Intensive Care Unit Brabois, France
| | - Nicolas Girerd
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433; Medical Intensive Care Unit Brabois, France
| | - Marion Kibler
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Hafid Ait-Oufella
- Intensive Care Unit, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM U970, Cardiovascular Research Center, Université de Paris, Paris, France
| | - Julie Helms
- Université de Strasbourg, Faculté de Médecine; Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), Unité Mixte de Recherche (UMR) 1260, Regenerative Nanomedicine, Strasbourg, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology, Burn and Critical Care, Saint Louis-Lariboisière University Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Conditions, Fédération Hospitalo-Universitaire Promice, University of Paris, Paris, France
| | - Bruno Levy
- INSERM U1116, Université de Lorraine, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Régional Universitaire de Nancy, France; and
| | - Antoine Kimmoun
- INSERM U1116, Université de Lorraine, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Régional Universitaire de Nancy, France; and
| | - Ferhat Meziani
- Université de Strasbourg, Faculté de Médecine; Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), Unité Mixte de Recherche (UMR) 1260, Regenerative Nanomedicine, Strasbourg, France
- Clinical Research in Intensive Care and Sepsis Trial Group for Global Evaluation and Research in Sepsis French Clinical Research Infrastructure Network, France
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21
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Messina A, Bakker J, Chew M, De Backer D, Hamzaoui O, Hernandez G, Myatra SN, Monnet X, Ostermann M, Pinsky M, Teboul JL, Cecconi M. Pathophysiology of fluid administration in critically ill patients. Intensive Care Med Exp 2022; 10:46. [PMID: 36329266 PMCID: PMC9633880 DOI: 10.1186/s40635-022-00473-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Fluid administration is a cornerstone of treatment of critically ill patients. The aim of this review is to reappraise the pathophysiology of fluid therapy, considering the mechanisms related to the interplay of flow and pressure variables, the systemic response to the shock syndrome, the effects of different types of fluids administered and the concept of preload dependency responsiveness. In this context, the relationship between preload, stroke volume (SV) and fluid administration is that the volume infused has to be large enough to increase the driving pressure for venous return, and that the resulting increase in end-diastolic volume produces an increase in SV only if both ventricles are operating on the steep part of the curve. As a consequence, fluids should be given as drugs and, accordingly, the dose and the rate of administration impact on the final outcome. Titrating fluid therapy in terms of overall volume infused but also considering the type of fluid used is a key component of fluid resuscitation. A single, reliable, and feasible physiological or biochemical parameter to define the balance between the changes in SV and oxygen delivery (i.e., coupling "macro" and "micro" circulation) is still not available, making the diagnosis of acute circulatory dysfunction primarily clinical.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
| | - Jan Bakker
- NYU Langone Health and Columbia University Irving Medical Center, New York, USA
- Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Michelle Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Olfa Hamzaoui
- Service de Reanimation PolyvalenteHopital Antoine Béclère, Hopitaux Universitaires Paris-Saclay, Clamart, France
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, Paris, France
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, Paris, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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22
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Odenbach J, Dhanoa S, Sebastianski M, Milovanovic L, Robinson A, Mah G, Rewa OG, Bagshaw SM, Buchanan B, Lau VI. Acute Respiratory Distress Syndrome and Shunt Detection With Bubble Studies: A Systematic Review and Meta-Analysis. Crit Care Explor 2022; 4:e0789. [PMID: 36382336 PMCID: PMC9646622 DOI: 10.1097/cce.0000000000000789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening respiratory injury with multiple physiological sequelae. Shunting of deoxygenated blood through intra- and extrapulmonary shunts may complicate ARDS management. Therefore, we conducted a systematic review to determine the prevalence of sonographically detected shunts, and their association with oxygenation and mortality in patients with ARDS. DATA SOURCES Medical literature analysis and retrieval system online, Excerpta Medica dataBASE, Cochrane Library, and database of abstracts of reviews of effects databases on March 26, 2021. STUDY SELECTION Articles relating to respiratory failure and sonographic shunt detection. DATA EXTRACTION Articles were independently screened and extracted in duplicate. Data pertaining to study demographics and shunt detection were compiled for mortality and oxygenation outcomes. Risk of bias was appraised using the Joanna-Briggs Institute and the Newcastle-Ottawa Scale tools with evidence rating certainty using Grading of Recommendations Assessment, Development and Evaluation methodology. DATA SYNTHESIS From 4,617 citations, 10 observational studies met eligibility criteria. Sonographic detection of right-to-left shunt was present in 21.8% of patients (range, 14.4-30.0%) among included studies using transthoracic, transesophageal, and transcranial bubble Doppler ultrasonographies. Shunt prevalence may be associated with increased mortality (risk ratio, 1.22; 95% CI, 1.01-1.49; p = 0.04, very low certainty evidence) with no difference in oxygenation as measured by Pao2:Fio2 ratio (mean difference, -0.7; 95% CI, -18.6 to 17.2; p = 0.94, very low certainty). CONCLUSIONS Intra- and extrapulmonary shunts are detected frequently in ARDS with ultrasound techniques. Shunts may increase mortality among patients with ARDS, but its association with oxygenation is uncertain.
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Affiliation(s)
- Jeffrey Odenbach
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Sumeet Dhanoa
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Meghan Sebastianski
- Alberta Strategy for Patient-Orientated Research Knowledge Translation Platform, University of Alberta, Edmonton, AB, Canada
| | - Lazar Milovanovic
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Andrea Robinson
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Graham Mah
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Brian Buchanan
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
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23
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Makris D, Tsolaki V, Robertson R, Dimopoulos G, Rello J. The future of training in intensive care medicine: A European perspective. JOURNAL OF INTENSIVE MEDICINE 2022; 3:52-61. [PMID: 36789360 PMCID: PMC9923960 DOI: 10.1016/j.jointm.2022.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - Ross Robertson
- Medical School, University of Thessaly, Larisa 41110, Greece
| | - George Dimopoulos
- Third Department of Critical Care, Medical School, National and Kapodistrian University of Athens, Athens 12462, Greece
| | - Jordi Rello
- CRIPS Department, Vall d'Hebron Institut of Research, Barcelona 08035, Spain,Clinical Research, CHU Nîmes, Nîmes 30029, France,Medical School, Universitat Internacional de Catalunya, Campus Sant Cugat, Sant Cugat del Valles, Barcelona 08195, Spain,Corresponding author: Jordi Rello, CRIPS Department, Vall d'Hebron Institut of Research, Barcelona 08035, Spain.
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24
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Suzuki R, Kanai M, Oya K, Harada Y, Horie R, Sekiguchi H. A prospective randomized study to compare standard versus intensive training strategies on long-term improvement in critical care ultrasonography proficiency. BMC MEDICAL EDUCATION 2022; 22:732. [PMID: 36280812 PMCID: PMC9594969 DOI: 10.1186/s12909-022-03780-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Critical care ultrasonography (CCUS) has become a daily diagnostic tool for intensivists. While the effective training measures for ultrasound novices are discussed widely, the best curriculum for the novices to retain a long-term proficiency is yet to be determined. METHODS Critical care medicine fellows who underwent an introductory CCUS workshop were randomly allocated into the standard training (ST) or the intensive training (IT) group. The IT group received an 8-h training besides the standardized fellowship education that the ST group received. Participant improvement in CCUS proficiency tests (maximum score, 200) after a 6-month training intervention was compared between the groups. CCUS examinations performed in patient care were observed over 2 years. RESULTS Twenty-one fellows were allocated into the ST (n = 10) or the IT (n = 11) group. No statistically significant difference was observed in the median (interquartile range [IQR]) improvement in CCUS proficiency tests between the ST group and the IT group: 18 (3.8-38) versus 31 (21-46) (P = .09). Median (IQR) test scores were significantly higher in postintervention than preintervention for both groups: ST, 103 (87-116) versus 124 (111-143) (P = .02), and IT, 100 (87-113) versus 143 (121-149) (P < .01). Participating fellows performed 226 examinations over the 2 years of observation. CONCLUSIONS Fellows improved their CCUS proficiency significantly after 6-month training intervention. However, an additional 8-h training did not provide further benefits.
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Affiliation(s)
- Reina Suzuki
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Mio Kanai
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kazumasa Oya
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Yohei Harada
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Ryohei Horie
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Hiroshi Sekiguchi
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, 85054, USA.
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25
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Douflé G, Urner M, Dragoi L, Jain A, Brydges R, Piquette D. Evaluation of an advanced critical care echocardiography program: a mixed methods study. Can J Anaesth 2022; 69:1260-1271. [PMID: 35819631 DOI: 10.1007/s12630-022-02281-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 03/04/2022] [Accepted: 04/11/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Limited data exist on advanced critical care echocardiography (CCE) training programs for intensivists. We sought to describe a longitudinal echocardiography program and investigate the effect of distributed conditional supervision vs predefined en-bloc supervision, as well as the effect of an optional echocardiography laboratory rotation, on learners' engagement. METHODS In this mixed methods study, we enrolled critical care fellows and faculty from five University of Toronto-affiliated intensive care units (ICU) between July 2015 and July 2018 in an advanced training program, comprising theoretical lectures and practical sessions. After the first year, the program was modified with changes to supervision model and inclusion of a rotation in the echo laboratory. We conducted semistructured interviews and investigated the effects of curricular changes on progress toward portfolio completion (150 transthoracic echocardiograms) using a Bayesian framework. RESULTS Sixty-five learners were enrolled and 18 were interviewed. Four (9%) learners completed the portfolio. Learners reported lack of time and supervision, and skill complexity as the main barriers to practicing independently. Conditional supervision was associated with a higher rate of submitting unsupervised echocardiograms than unconditional supervision (rate ratio, 1.11, 95% credible interval, 1.08 to 1.14). After rotation in the echocardiography laboratory, submission of unsupervised echocardiograms decreased. CONCLUSION Trainees perceived lack of time and limited access to supervision as major barriers to course completion. Nevertheless, successful portfolio completion was related to factors other than protected time in the echocardiography laboratory or unconditional direct supervision in ICU. Further research is needed to better understand the factors promoting success of CCE training programs.
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Affiliation(s)
- Ghislaine Douflé
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Aditi Jain
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Ryan Brydges
- The Wilson Centre for Research in Healthcare Education, University of Toronto, Toronto, ON, Canada
| | - Dominique Piquette
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- The Wilson Centre for Research in Healthcare Education, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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26
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Bagate F, Coppens A, Masi P, de Prost N, Carteaux G, Razazi K, Mekontso Dessap A. Cardiac and vascular effects of low-dose steroids during the early phase of septic shock: An echocardiographic study. Front Cardiovasc Med 2022; 9:948231. [PMID: 36225952 PMCID: PMC9549363 DOI: 10.3389/fcvm.2022.948231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/06/2022] [Indexed: 01/25/2023] Open
Abstract
BackgroundLow-dose steroids are known to increase arterial pressure during septic shock through restoration of vasopressor response to norepinephrine. However, their effects on cardiac performance and ventriculo-arterial coupling (VAC) have never been scrutinized during human septic shock. The aim of this study was to perform a comprehensive description of the cardiovascular effects of low-dose steroids using modern echocardiographic tools (including speckle tracking imaging).MethodsThis prospective study was conducted in the intensive care unit (ICU) of a university hospital in France. Consecutive adult patients admitted for septic shock and requiring low-dose steroid therapy were prospectively enrolled within 24 h of septic shock onset. We recorded hemodynamic and echocardiographic data to explore left ventricle (LV) contractility, loading conditions and VAC just before the initiation of low-dose steroids (50 mg intravenous hydrocortisone plus 50 μg enteral fludrocortisone) and 2–4 h after.ResultsFifty patients [65 (55–73) years; 33 men] were enrolled. Arterial pressure, heart rate, almost all LV afterload parameters, and most cardiac contractility parameters significantly improved after steroids. VAC improved with steroid therapy and less patients had uncoupled VAC (> 1.36) after (24%) than before (44%) treatment.ConclusionIn this comprehensive echocardiographic study, we confirmed an improvement of LV afterload after initiation of low-dose steroids. We also observed an increase in LV contractility with improved cardiovascular efficiency (less uncoupling with decreased VAC).
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Affiliation(s)
- François Bagate
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
- *Correspondence: François Bagate,
| | - Alexandre Coppens
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
| | - Paul Masi
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Nicolas de Prost
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Guillaume Carteaux
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Keyvan Razazi
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Armand Mekontso Dessap
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, Créteil, France
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27
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Yastrebov K, McLean A, Hilton A, Evans J. Reflections on Australian critical care echocardiography. CRIT CARE RESUSC 2022; 24:212-217. [PMID: 38046207 PMCID: PMC10692623 DOI: 10.51893/2022.3.sa2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Konstantin Yastrebov
- Prince of Wales Hospital, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Anthony McLean
- Nepean Hospital, Sydney, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
| | - Andrew Hilton
- Austin Hospital, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - John Evans
- Townsville Hospital, Townsville, QLD, Australia
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28
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Vives M, Hernández A, Carmona P, Villen T, Borrat X, Sánchez E, Nagore D, González AD, Cuesta P, Serna M, Campo R, Bengoetxea U, Mercadal J. Diploma on Basic Echocardiography training and competencies for Intensive Care and Emergency medicine: Consensus document of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:402-410. [PMID: 35871144 DOI: 10.1016/j.redare.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 05/09/2021] [Indexed: 06/15/2023]
Abstract
Cardiac ultrasound has become an essential tool for diagnosis and hemodynamic monitoring in critically ill patients. Scientific societies need to work toward developing a training program that will allow clinicians to acquire competence in performing cardiac ultrasound and understanding its indications. The Clinical Ultrasound for Intensive Care task force of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES) have drawn up this position statement defining the learning objectives and training required to acquire the competencies recommended for basic ultrasound management in the intensive care and emergency setting in order to obtain a diploma in Basic Ultrasound in Intensive Care and Emergency Medicine. This document defines the training program and the competencies needed for basic skills in ultrasound in Intensive Care and Emergency Medicine-part of the Diploma in Ultrasound for Intensive Care and Emergency Medicine awarded by SEDAR/SEMES. The Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES) have drawn up a position statement determining the competencies and training program for a diploma in ultrasound (lung, abdominal and vascular) in Intensive Care and Emergency Medicine. To obtain the SEDAR/SEMES Diploma in Ultrasound in Intensive Care and Emergency Medicine, clinicians must have completed the SEDAR, SEMI and SEMES Diploma in basic ultrasound and the Diploma in lung, abdominal, and vascular ultrasound.
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Affiliation(s)
- M Vives
- Co-directores del Grupo de trabajo de Ecografía Clínica en Cuidados Intensivos de la SEDAR; Unidad de Reanimación Posquirúrgica, Servicio de Anestesiología y Reanimación. Hospital Universitario de Girona Dr. J Trueta. Institut d'Investigació Biomèdica de Girona (IDIBGI), Universitat de Girona, Girona, Spain. Representante en España de la «European Association of Cardiothoracic Anesthesia and Intensive Care» (EACTAIC).
| | - A Hernández
- Unidad de Reanimación Posquirúrgica, Servicio de Anestesiología y Reanimación, Grupo Policlínica, Ibiza, Spain. Board member del Subcomité de Cuidados Intensivos de la EACTAIC
| | - P Carmona
- Unidad de Reanimación Posquirúrgica, Servicio de Anestesiología y Reanimación, Hospital Universitario La Fe, Valencia, Spain
| | - T Villen
- Director del Grupo de trabajo de Ecografía Clínica en Urgencias y Emergencias de la SEMES; Servicio de Urgencias, Hospital Universitario La Paz, Madrid, Spain
| | - X Borrat
- Unidad de Cuidados Intensivos Postquirúrgica, Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, Spain
| | - E Sánchez
- Unidad de Reanimación Postquirúrgica, Servicio de Anestesiología y Reanimación, Hospital Gregorio Marañón, Madrid, Spain
| | - D Nagore
- Intensive Care Unit, Department of Anaesthesia & Intensive Care, Barts Heart Center, Barts Health NHS Trust, London, UK
| | - A D González
- Unidad de Cuidados Intensivos, Servicio de Anestesiología y Reanimación, Clínica Universidad de Navarra, Pamplona, Spain
| | - P Cuesta
- Unidad de Reanimación Postquirúrgica, Servicio de Anestesiología y Reanimación, Hospital Universitario de Albacete, Spain
| | - M Serna
- Unidad de Reanimación Postquirúrgica, Servicio de Anestesiología y Reanimación, Hospital Universitario de Denia, Spain
| | - R Campo
- Servicio de Urgencias, Hospital Santa Bárbara de Puertollano, Ciudad Real, Spain
| | - U Bengoetxea
- Unidad de Reanimación Postquirúrgica, Servicio de Anestesiología y Reanimación, Hospital de Urduliz, Bilbao, Spain
| | - J Mercadal
- Co-directores del Grupo de trabajo de Ecografía Clínica en Cuidados Intensivos de la SEDAR; Unidad de Cuidados Intensivos Postquirúrgica, Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, Spain; Coordinador de la Sección de Críticos de la Sociedad Catalana de Anestesiología y Reanimación (SCARDT)
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29
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Lanspa MJ, Fox SW, Sohn J, Dugar S, Klick JC, Diaz-Gomez J, Liu R, Panebianco N. Definitive Advantages of Point-of-Care Ultrasound: A Case Series. CASE (PHILADELPHIA, PA.) 2022; 6:293-298. [PMID: 36036052 PMCID: PMC9399626 DOI: 10.1016/j.case.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
•We describe 4 cases where POCUS changed or aided in diagnosis. •POCUS often provides useful information in patients in shock. •Serial POCUS can assess changes over time in the ICU.
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Affiliation(s)
- Michael J. Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, Utah
| | - Steven W. Fox
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jaqueline Sohn
- Cardiovascular Anesthesia and Critical Care Medicine, Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, Texas
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - John C. Klick
- Department of Anesthesiology, University of Vermont, Burlington, Vermont
| | - Jose Diaz-Gomez
- Cardiovascular Anesthesia and Critical Care Medicine, Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, Texas
| | - Rachel Liu
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nova Panebianco
- Department of Emergency Medicine Ultrasound, University of Pennsylvania, Philadelphia, Pennsylvania
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Transthoracic echocardiography is very valuable and not overused in surgical and trauma intensive care! Injury 2022; 53:2696-2697. [PMID: 35365347 DOI: 10.1016/j.injury.2022.03.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 02/02/2023]
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Sattin M, Burhani Z, Jaidka A, Millington SJ, Arntfield RT. Stroke Volume Determination by Echocardiography. Chest 2022; 161:1598-1605. [PMID: 35085589 DOI: 10.1016/j.chest.2022.01.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 01/31/2023] Open
Abstract
Basic critical care echocardiography emphasizes two-dimensional (2D) findings, such as ventricular function, inferior vena cava size, and pericardial assessment, while generally excluding quantitative findings and Doppler-based techniques. Although this approach offers advantages, including efficiency and expedited training, it complicates attempts to understand the hemodynamic importance of any 2D abnormalities detected. Stroke volume (SV), as the summative event of the cardiac cycle, is the most pragmatic available indicator through which a clinician can rapidly determine, no matter the 2D findings, whether aberrant cardiac physiology is contributing to the state of shock. An estimate of SV allows 2D findings to be placed into better context in terms of both hemodynamic significance and acuity. This article describes the technique of SV determination, reviews common confounding factors and pitfalls, and suggests a systematic approach for using SV measurements to help integrate important 2D findings into the clinical context.
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Affiliation(s)
| | - Zain Burhani
- University of Western Ontario, London, ON, Canada
| | - Atul Jaidka
- University of Western Ontario, London, ON, Canada
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Weber AG, Mastroianni F, Koenig S, Mayo PH. Transesophageal Lung Ultrasonography as Part of the Critical Care Transesophageal Echocardiography Examination. Chest 2022; 161:e335-e336. [DOI: 10.1016/j.chest.2022.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/16/2022] [Indexed: 11/26/2022] Open
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Lafon T, Baisse A, Simonneau Y, Goudelin M, Hani Karam H, Desvaux E, Guillot MS, Evrard B, Vignon P. Identification précoce des phénotypes cardiovasculaires chez les patients en insuffisance respiratoire aiguë au cours de la première pandémie Covid-19. ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectif : L'objectif principal était de comparer la prévalence de la dysfonction ventriculaire gauche (VG) et/ ou droite (VD) des patients admis au service d'urgence (SU) avec une insuffisance respiratoire aiguë (IRA) secondaire ou non à une pneumopathie à Covid-19.
Méthodes : Pendant un mois, nous avons inclus (24/7) de façon prospective les patients de l'unité de Covid-19 du SU qui présentaient une IRA. Pour chaque patient, un test RT-PCR, une tomodensitométrie thoracique et une échographie cardiaque de niveau 2 et pulmonaire étaient systématiquement réalisés avant toute intervention thérapeutique. Chaque patient était classé selon les phénotypes cardiovasculaires suivants : insuffisance VG, insuffisance VD, hypovolémie ± hyperkinésie et profil hémodynamique normal.
Résultats : Parmi les 517 patients admis pendant la période d'étude, 78 présentaient une IRA (15 %) et 62 ont bénéficié d'une échocardiographie de niveau 2 (âge : 73 ± 14 ans ; SpO2 : 90 ± 4 % ; lactate : 2,1 ± 1,3 mmol/l). Le diagnostic de la Covid-19 a été établi pour 22 patients (35 %). L'insuffisance VG (15 [38 %] vs 2 [9 %] ; p = 0,016) et celle VD (12 [30 %] vs 1 [5 %] ; p = 0,018) étaient plus souvent observées dans le groupe témoin que chez les patients ayant une pneumopathie à Covid-19. Inversement, les patients Covid-19 avaient plus fréquemment un profil hémodynamique normal ou une hypovolémie associée ou non à une vasoplégie (20 [91 %] vs 21 [53 %] ; p = 0,002). La mortalité intrahospitalière était de 18 % ( n = 11). Tous les patients atteints de la Covid-19 présentant une insuffisance VG et/ou VD précoce sont décédés pendant leur hospitalisation.
Conclusions : La dysfonction VG et celle VD étaient plus fréquentes chez les patients non atteints de la Covid-19, alors que les patients atteints de Covid-19 avaient un phénotype cardiovasculaire normal ou hypovolémique.
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Schmidt S, Dieks JK, Quintel M, Moerer O. Hemodynamic profiling by critical care echocardiography could be more accurate than invasive techniques and help identify targets for treatment. Sci Rep 2022; 12:7187. [PMID: 35504927 PMCID: PMC9065036 DOI: 10.1038/s41598-022-11252-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/19/2022] [Indexed: 11/08/2022] Open
Abstract
In this prospective observational study, non-invasive critical care echocardiography (CCE) was used to obtain quantitative hemodynamic parameters in 107 intensive care unit (ICU) patients; the parameters were then visualized in a novel web graph approach to increase the understanding and impact of CCE abnormalities, as an alternative to thermodilution techniques. Visualizing the CCE hemodynamic data in six-dimensional web graph plots was feasible in almost all ICU patients. In 23.1% of patients, significant tricuspid regurgitation prevented correlation between thermodilution techniques and echocardiographic hemodynamics. Two parameters of longitudinal right ventricular function (TAPSE and S') did not correlate in ICU patients. Clinical surrogate parameters of hemodynamic compromise did not correlate with measured hemodynamics. 26.2% of the patients with mean arterial pressures above 60 mmHg had cardiac indices (CI) below 2.5 L min-1·m-2. A CI below 2.2 L·min-1·m-2 was associated with a significant ICU survival disadvantage. CCE was feasible in addition or as an alternative to thermodilution techniques for the hemodynamic evaluation of ICU patients. Six-dimensional web graph plots visualized the hemodynamic states and were especially useful in conditions in which thermodilution methods were not reliable. Hemodynamic CCE identified patients with previously unknown low CI, which correlated with a higher ICU mortality.
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Affiliation(s)
- Stefan Schmidt
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Jana-Katharina Dieks
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany.
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
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Impact of Deliberate Practice on Point-of-Care Ultrasound Interpretation of Right Ventricle Pathology. ATS Sch 2022; 3:229-241. [PMID: 35924202 PMCID: PMC9341488 DOI: 10.34197/ats-scholar.2021-0080oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/14/2021] [Indexed: 11/18/2022] Open
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Mayo PH, Chew M, Douflé G, Mekontso-Dessap A, Narasimhan M, Vieillard-Baron A. Machines that save lives in the intensive care unit: the ultrasonography machine. Intensive Care Med 2022; 48:1429-1438. [PMID: 35941260 PMCID: PMC9360728 DOI: 10.1007/s00134-022-06804-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/23/2022] [Indexed: 02/04/2023]
Abstract
This article highlights the ultrasonography machine as a machine that saves lives in the intensive care unit. We review its utility in the limited resource intensive care unit and some elements of machine design that are relevant to both the constrained operating environment and the well-resourced intensive care unit. As the ultrasonography machine can only save lives, if is operated by a competent intensivist; we discuss the challenges of training the frontline clinician to become competent in critical care ultrasonography followed by a review of research that supports its use.
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Affiliation(s)
- Paul H. Mayo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Northwell Health LIJ/NSUH Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
| | - Michelle Chew
- Department of Anaesthesiology and Intensive Care Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Ghislaine Douflé
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada ,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Armand Mekontso-Dessap
- AP-HP Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 94010 Créteil, France ,Univ Paris Est Créteil, CARMAS, 94010 Créteil, France ,Univ Paris Est Créteil, INSERM, IMRB, 94010 Créteil, France
| | - Mangala Narasimhan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Northwell Health LIJ/NSUH Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
| | - Antoine Vieillard-Baron
- Intensive Care Medicine, University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, 92100 Boulogne-Billancourt, France
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Schmidt S, Dieks JK, Quintel M, Moerer O. Development and evaluation of the focused assessment of sonographic pathologies in the intensive care unit (FASP-ICU) protocol. Crit Care 2021; 25:405. [PMID: 34819132 PMCID: PMC8611927 DOI: 10.1186/s13054-021-03811-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 11/03/2021] [Indexed: 11/11/2022] Open
Abstract
Background The use of ultrasonography in the intensive care unit (ICU) is steadily increasing but is usually restricted to examinations of single organs or organ systems. In this study, we combine the ultrasound approaches the most relevant to ICU to design a whole-body ultrasound (WBU) protocol. Recommendations and training schemes for WBU are sparse and lack conclusive evidence. Our aim was therefore to define the range and prevalence of abnormalities detectable by WBU to develop a simple and fast bedside examination protocol, and to evaluate the value of routine surveillance WBU in ICU patients. Methods A protocol for focused assessments of sonographic abnormalities of the ocular, vascular, pulmonary, cardiac and abdominal systems was developed to evaluate 99 predefined sonographic entities on the day of admission and on days 3, 6, 10 and 15 of the ICU admission. The study was a clinical prospective single-center trial in 111 consecutive patients admitted to the surgical ICUs of a tertiary university hospital. Results A total of 3003 abnormalities demonstrable by sonography were detected in 1275 individual scans of organ systems and 4395 individual single-organ examinations. The rate of previously undetected abnormalities ranged from 6.4 ± 4.2 on the day of admission to 2.9 ± 1.8 on day 15. Based on the sonographic findings, intensive care therapy was altered following 45.1% of examinations. Mean examination time was 18.7 ± 3.2 min, or 1.6 invested minutes per detected abnormality. Conclusions Performing the WBU protocol led to therapy changes in 45.1% of the time. Detected sonographic abnormalities showed a high rate of change in the course of the serial assessments, underlining the value of routine ultrasound examinations in the ICU. Trial registration The study was registered in the German Clinical Trials Register (DRKS, 7 April 2017; retrospectively registered) under the identifier DRKS00010428. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03811-2.
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Affiliation(s)
- Stefan Schmidt
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Goettingen, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Jana-Katharina Dieks
- Department of Pediatric Cardiology and Pediatric Intensive Care Medicine, University Hospital Goettingen, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany.
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Goettingen, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Goettingen, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany
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Teaching Ultrasound at the Point of Care in Times of Social Distancing. ATS Sch 2021; 2:341-352. [PMID: 34667984 PMCID: PMC8519320 DOI: 10.34197/ats-scholar.2021-0023ps] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/09/2021] [Indexed: 11/18/2022] Open
Abstract
Point-of-care ultrasound has become an integral aspect of critical care training. The Bedside Assessment by Sonography In Critical Care Medicine Curriculum was established at the University of Toronto to train critical care trainees in basic echocardiography and general critical care ultrasound. During the coronavirus disease (COVID-19) pandemic, our program needed to adapt quickly to ensure staff safety and adherence to infection-control protocols. In this article, we share our experience and reflect on the challenges and benefits of shifting from a primarily in-person teaching model to a hybrid model of remote and in-person teaching. Curricular changes were threefold: the transition to entirely web-based interactive didactic teaching and online imaging interpretation modules, the recruitment of sonographers at multiple academic sites as instructors to facilitate in-person practices with lower instructor to trainee ratio, and the use of a mobile application for informal group case-based discussions. Challenges included lost opportunities for scanning healthy volunteers, variability in attendance at online lectures, and a lower number of study submissions for review. However, curricular changes enabled maintenance of directly observed practice, high levels of engagement with recorded content, and an expansion of our reach to a global audience. We believe that future curricula should combine high-quality online curriculum and resources with the ongoing in-person delivery of key elements of curriculum to allow for direct observation and feedback as well as the maintenance of self-directed point-of-care ultrasound portfolios.
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Labbé V, Ederhy S, Lapidus N, Joffre J, Razazi K, Laine L, Sy O, Voicu S, Chemouni F, Aissaoui N, Smonig R, Doyen D, Carrat F, Voiriot G, Mekontso-Dessap A, Cohen A, Fartoukh M. Transesophageal echocardiography for cardiovascular risk estimation in patients with sepsis and new-onset atrial fibrillation: a multicenter prospective pilot study. Ann Intensive Care 2021; 11:146. [PMID: 34661761 PMCID: PMC8523595 DOI: 10.1186/s13613-021-00934-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/02/2021] [Indexed: 12/25/2022] Open
Abstract
Background Echocardiographic parameters have been poorly investigated for estimating cardiovascular risk in patients with sepsis and new-onset atrial fibrillation. We aim to assess the prevalence of transesophageal echocardiographic abnormalities and their relationship with cardiovascular events in mechanically ventilated patients with sepsis and new-onset atrial fibrillation. Methods In this prospective multicenter pilot study, left atrial/left atrial appendage (LA/LAA) dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were assessed using an initial transesophageal echocardiographic study, which was repeated after 48–72 h to detect LA/LAA thrombus formation. The study outcome was a composite of cardiovascular events at day 28, including arterial thromboembolic events (ischemic stroke, non-cerebrovascular arterial thromboembolism, LA/LAA thrombus), major bleeding, and all-cause death. Results The study population comprised 94 patients (septic shock 63%; 35% women; median age 69 years). LA/LAA dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were detected in 17 (19%), 22 (24%), and 27 (29%) patients, respectively. At day 28, the incidence of cardiovascular events was 46% (95% confidence interval [CI]: 35 to 56). Arterial thromboembolic events and major bleeding occurred in 7 (7%) patients (5 ischemic strokes, 1 non-cerebrovascular arterial thromboembolism, 2 left atrial appendage thrombi) and 18 (19%) patients, respectively. At day 28, 27 patients (29%) died. Septic shock (hazard ratio [HR]: 2.36; 95% CI 1.06 to 5.29) and left ventricular systolic dysfunction (HR: 2.06; 95% CI 1.05 to 4.05) were independently associated with cardiovascular events. Conclusions Transesophageal echocardiographic abnormalities are common in mechanically ventilated patients with sepsis and new-onset atrial fibrillation, but only left ventricular systolic dysfunction was associated with cardiovascular events at day 28. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00934-1.
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Affiliation(s)
- Vincent Labbé
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France. .,Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France.
| | - Stephane Ederhy
- Department of Cardiology, UNICO Cardio-Oncology Program, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM U 856, Paris, France
| | - Nathanael Lapidus
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Paris, France.,Sorbonne Université, Public Health Department, Saint Antoine Hospital, AP-HP, Paris, France
| | - Jérémie Joffre
- Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, AP-HP, Sorbonne Université, Paris, France
| | - Keyvan Razazi
- Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France.,Service de Médecine Intensive Réanimation, Département Médico-Universitaire Médecine, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, AP-HP, Créteil, France
| | - Laurent Laine
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint-Denis, Saint Denis, France
| | - Oumar Sy
- Service de Médecine Intensive Réanimation, Groupe Hospitalier Sud Ile-de-France, Centre Hospitalier Melun, Melun, France
| | - Sebastian Voicu
- Service de Réanimation Médicale et Toxicologique, Hôpital Lariboisière, AP-HP, INSERM UMRS-1144, Université de Paris, Paris, France
| | - Frank Chemouni
- Service de Médecine Intensive Réanimation, Gustave Roussy, Villejuif, France
| | - Nadia Aissaoui
- Service de Médecine Intensive Réanimation, Hôpital Européen Georges-Pompidou, AP-HP, Université Paris-Descartes, Paris, France
| | - Roland Smonig
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France
| | - Denis Doyen
- Service de Médecine Intensive Réanimation, Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, and UR2CA Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Fabrice Carrat
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Paris, France.,Sorbonne Université, Public Health Department, Saint Antoine Hospital, AP-HP, Paris, France
| | - Guillaume Voiriot
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France.,Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France
| | - Armand Mekontso-Dessap
- Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France.,Service de Médecine Intensive Réanimation, Département Médico-Universitaire Médecine, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, AP-HP, Créteil, France
| | - Ariel Cohen
- Department of Cardiology, UNICO Cardio-Oncology Program, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM U 856, Paris, France.,UMR-S ICAN 1166, Sorbonne Université, Paris, France
| | - Muriel Fartoukh
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France.,Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France
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Watkins LA, Dial SP, Koenig SJ, Kurepa DN, Mayo PH. The Utility of Point-of-Care Ultrasound in the Pediatric Intensive Care Unit. J Intensive Care Med 2021; 37:1029-1036. [PMID: 34632837 DOI: 10.1177/08850666211047824] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objectives: Point of care ultrasound (POCUS) in adult critical care environments has become the standard of care in many hospitals. A robust literature shows its benefits for both diagnosis and delivery of care. The utility of POCUS in the pediatric intensive care unit (PICU), however, is understudied. This study describes in a series of PICU patients the clinical indications, protocols, findings and impact of pediatric POCUS on clinical management. Design: Retrospective analysis of 200 consecutive POCUS scans performed by a PICU physician. Patients: Pediatric critical care patients who required POCUS scans over a 15-month period. Setting: The pediatric and cardiac ICUs at a tertiary pediatric care center. Interventions: Performance of a POCUS scan by a pediatric critical care attending with advanced training in ultrasonography. Measurement and Main Results: A total of 200 POCUS scans comprised of one or more protocols (lung and pleura, cardiac, abdominal, or vascular diagnostic protocols) were performed on 155 patients over a 15-month period. The protocols used for each scan reflected the clinical question to be answered. These 200 scans included 133 thoracic protocols, 110 cardiac protocols, 77 abdominal protocols, and 4 vascular protocols. In this series, 42% of scans identified pathology that required a change in therapy, 26% confirmed pathology consistent with the ongoing plans for new therapy, and 32% identified pathology that did not result in initiation of a new therapy. Conclusions: POCUS performed by a trained pediatric intensivist provided useful clinical information to guide patient management.
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Affiliation(s)
- Laura A Watkins
- 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- 6923Present Affiliation: University of Rochester, Rochester, NY, USA
| | - Sharon P Dial
- 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Seth J Koenig
- 2006Albert Einstein College of Medicine, Bronx, NY, USA
| | - Dalibor N Kurepa
- 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Paul H Mayo
- 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- 5799Northwell LIJ/NSUH Hospital, New Hyde Park, NY, USA
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Cheng J, Arntfield R. Training strategies for point of care ultrasound in the ICU. Curr Opin Anaesthesiol 2021; 34:654-658. [PMID: 34310365 DOI: 10.1097/aco.0000000000001042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Ultrasound in critical care medicine (CCUS) is a relatively young tool that has been evolving rapidly as skillsets, applications and technology continue to progress. Although ultrasound is identified as a core competency in intensive care unit (ICU) training, there remains significant variability and inconsistencies in the delivery of ultrasound training. The goal of this narrative review is to explore areas of consensus and highlight areas where consensus is lacking to bring attention to future directions of ultrasound training in critical care medicine. RECENT FINDINGS There exists considerable variation in competencies identified as basic for CCUS. Recent efforts by the European Society of Intensive Care Medicine serve as the most up to date iteration however implementation is still limited by regional expertise and practice patterns. Major barriers to ultrasound training in the ICU include a lack of available experts for bedside teaching and a lack of familiarity with new technology. SUMMARY Though international uptake of CCUS has made many gains in the past 20 years, further adoption of technology will be required to overcome the traditional barriers of CCUS training. Although the availability and time constraints of experts will remain a limitation even with wireless capabilities, the ability to expand beyond the physical constraints of an ultrasound machine will vastly benefit efforts to standardize training and improve access to knowledge.
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Affiliation(s)
- Jason Cheng
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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Left ventricular longitudinal strain variations assessed by speckle-tracking echocardiography after a passive leg raising maneuver in patients with acute circulatory failure to predict fluid responsiveness: A prospective, observational study. PLoS One 2021; 16:e0257737. [PMID: 34591884 PMCID: PMC8483378 DOI: 10.1371/journal.pone.0257737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 09/08/2021] [Indexed: 01/22/2023] Open
Abstract
Background An association was reported between the left ventricular longitudinal strain (LV-LS) and preload. LV-LS reflects the left cardiac function curve as it is the ratio of shortening over diastolic dimension. The aim of this study was to determine the sensitivity and specificity of LV-LS variations after a passive leg raising (PLR) maneuver to predict fluid responsiveness in intensive care unit (ICU) patients with acute circulatory failure (ACF). Methods Patients with ACF were prospectively included. Preload-dependency was defined as a velocity time integral (VTI) variation greater than 10% between baseline (T0) and PLR (T1), distinguishing the preload-dependent (PLD+) group and the preload-independent (PLD-) group. A 7-cycles, 4-chamber echocardiography loop was registered at T0 and T1, and strain analysis was performed off-line by a blind clinician. A general linear model for repeated measures was used to compare the LV-LS variation (T0 to T1) between the two groups. Results From June 2018 to August 2019, 60 patients (PLD+ = 33, PLD- = 27) were consecutively enrolled. The VTI variations after PLR were +21% (±8) in the PLD+ group and -1% (±7) in the PLD- group (p<0.01). Mean baseline LV-LS was -11.3% (±4.2) in the PLD+ group and -13.0% (±4.2) in the PLD- group (p = 0.12). LV-LS increased in the whole population after PLR +16.0% (±4.0) (p = 0.04). The LV-LS variations after PLR were +19.0% (±31) (p = 0.05) in the PLD+ group and +11.0% (±38) (p = 0.25) in the PLD- group, with no significant difference between the two groups (p = 0.08). The area under the curve for the LV-LS variations between T0 and T1 was 0.63 [0.48–0.77]. Conclusion Our study confirms that LV-LS is load-dependent; however, the variations in LV-LS after PLR is not a discriminating criterion to predict fluid responsiveness of ICU patients with ACF in this cohort.
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Transpulmonary thermodilution in patients treated with veno-venous extracorporeal membrane oxygenation. Ann Intensive Care 2021; 11:101. [PMID: 34213674 PMCID: PMC8249841 DOI: 10.1186/s13613-021-00890-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/21/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We tested the effect of different blood flow levels in the extracorporeal circuit on the measurements of cardiac stroke volume (SV), global end-diastolic volume index (GEDVI) and extravascular lung water index derived from transpulmonary thermodilution (TPTD) in 20 patients with severe acute respiratory distress syndrome (ARDS) treated with veno-venous extracorporeal membrane oxygenation (ECMO). METHODS Comparative SV measurements with transesophageal echocardiography and TPTD were performed at least 5 times during the treatment of the patients. The data were interpreted with a Bland-Altman analysis corrected for repeated measurements. The interchangeability between both measurement modalities was calculated and the effects of extracorporeal blood flow on SV measurements with TPTD was analysed with a linear mixed effect model. GEDVI and EVLWI measurements were performed immediately before the termination of the ECMO therapy at a blood flow of 6 l/min, 4 l/min and 2 l/min and after the disconnection of the circuit in 7 patients. RESULTS 170 pairs of comparative SV measurements were analysed. Average difference between the two modalities (bias) was 0.28 ml with an upper level of agreement of 40 ml and a lower level of agreement of -39 ml within a 95% confidence interval and an overall interchangeability rate between TPTD and Echo of 64%. ECMO blood flow did not influence the mean bias between Echo and TPTD (0.03 ml per l/min of ECMO blood flow; p = 0.992; CI - 6.74 to 6.81). GEDVI measurement was not significantly influenced by the blood flow in the ECMO circuit, whereas EVLWI differed at a blood flow of 6 l/min compared to no ECMO flow (25.9 ± 10.1 vs. 11.0 ± 4.2 ml/kg, p = 0.0035). CONCLUSIONS Irrespectively of an established ECMO therapy, comparative SV measurements with Echo and TPTD are not interchangeable. Such caveats also apply to the interpretation of EVLWI, especially with a high blood flow in the extracorporeal circulation. In such situations, the clinician should rely on other methods of evaluation of the amount of lung oedema with the haemodynamic situation, vasopressor support and cumulative fluid balance in mind. TRIAL REGISTRATION German Clinical Trials Register (DRKS00021050). Registered 03/30/2020 https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017237.
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Sivakorn C, Schultz MJ, Dondorp AM. How to monitor cardiovascular function in critical illness in resource-limited settings. Curr Opin Crit Care 2021; 27:274-281. [PMID: 33899817 PMCID: PMC8240644 DOI: 10.1097/mcc.0000000000000830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hemodynamic monitoring is an essential component in the care for critically ill patients. A range of tools are available and new approaches have been developed. This review summarizes their availability, affordability and feasibility for hospital settings in resource-limited settings. RECENT FINDINGS Evidence for the performance of specific hemodynamic monitoring tools or strategies in low-income and middle-income countries (LMICs) is limited. Repeated physical examination and basic observations remain a cornerstone for patient monitoring and have a high sensitivity for detecting organ hypoperfusion, but with a low specificity. Additional feasible approaches for hemodynamic monitoring in LMICs include: for tissue perfusion monitoring: urine output, skin mottling score, capillary refill time, skin temperature gradients, and blood lactate measurements; for cardiovascular monitoring: echocardiography and noninvasive or minimally invasive cardiac output measurements; and for fluid status monitoring: inferior vena cava distensibility index, mini-fluid challenge test, passive leg raising test, end-expiratory occlusion test and lung ultrasound. Tools with currently limited applicability in LMICs include microcirculatory monitoring devices and pulmonary artery catheterization, because of costs and limited added value. Especially ultrasound is a promising and affordable monitoring device for LMICs, and is increasingly available. SUMMARY A set of basic tools and approaches is available for adequate hemodynamic monitoring in resource-limited settings. Future research should focus on the development and trialing of robust and context-appropriate monitoring technologies.
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Affiliation(s)
| | - Marcus J. Schultz
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine Mahidol University, Bangkok, Thailand
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Arjen M. Dondorp
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine Mahidol University, Bangkok, Thailand
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
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Duclos G, Bazalguette F, Allaouchiche B, Mohammedi N, Lopez A, Gazon M, Besch G, Bouvet L, Muller L, Mathon G, Arbelot C, Boucekine M, Leone M, Zieleskiewicz L. Can Thoracic Ultrasound on Admission Predict the Outcome of Critically Ill Patients with SARS-CoV-2? A French Multi-Centric Ancillary Retrospective Study. Adv Ther 2021; 38:2599-2612. [PMID: 33852149 PMCID: PMC8045017 DOI: 10.1007/s12325-021-01702-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/10/2021] [Indexed: 12/26/2022]
Abstract
Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have led to massive admissions to intensive care units (ICUs). An ultrasound examination of the thorax is widely performed on admission in these patients. The primary objective of our study was to assess the performance of the lung ultrasound score (LUS) on ICU admission to predict the 28-day mortality rate in patients with SARS-CoV-2. The secondary objective was to asses the performance of thoracic ultrasound and biological markers of cardiac injury to predict mortality. Methods This multicentre, retrospective, observational study was conducted in six ICUs of four university hospitals in France from 15 March to 3 May 2020. Patients admitted to ICUs because of SARS-CoV-2-related acute respiratory failure and those who received an LUS examination at admission were included. The area under the receiver-operating characteristics (ROC) curve was determined for the LUS score to predict the 28-day mortality rate. The same analysis was performed for the Simplified Acute Physiology Score, left ventricular ejection fraction, cardiac output, brain natriuretic peptide and ultra-sensitive troponin levels at admission. Results In 57 patients, the 28-day mortality rate was 21%. The area under the ROC curve of the LUS score value on ICU admission was 0.68 [95% CI 0.54–0.82; p = 0.05]. In non-intubated patients on ICU admission (n = 40), the area under the ROC curves was 0.84 [95% CI 0.70–0.97; p = 0.005]. The best cut-off of 22 corresponded to 85% specificity and 83% sensitivity. Conclusions LUS scores on ICU admission for SARS-CoV-2 did not efficiently predict the 28-day mortality rate. Performance was better for non-intubated patients at admission. Performance of biological cardiac markers may be equivalent to the LUS score. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01702-0.
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Affiliation(s)
- Gary Duclos
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Nord Hospital, Marseille, France.
| | - Florian Bazalguette
- CHU de Nîmes-Caremeau, Service Réanimation et Surveillance Continue, Pôle ARDU (anesthésie, réanimation, douleur, urgences), 30029, Nîmes cedex, France
| | - Bernard Allaouchiche
- Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Service de Réanimation, 69310, Pierre-Bénite, France
- Université Claude, Bernard-Lyon-1, Lyon, France
- Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, UPSP 2016.A101, Pulmonary and Cardiovascular Agression in Sepsis APCSe, 69280, Marcy l'Étoile, France
| | - Neyla Mohammedi
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Nord Hospital, Marseille, France
| | - Alexandre Lopez
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Nord Hospital, Marseille, France
| | - Mathieu Gazon
- Département d'Anesthésie et Réanimation and Centre de Recherche Clinique, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Besch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France
- EA 3920, University of Franche-Comte, Besancon, France
| | - Lionel Bouvet
- Service d'Anesthésie Réanimation, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
- Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, UPSP 2016.A101, Pulmonary and Cardiovascular Aggression in Sepsis, 69280, Marcy l'Étoile, France
| | - Laurent Muller
- CHU de Nîmes-Caremeau, Service Réanimation et Surveillance Continue, Pôle ARDU (anesthésie, réanimation, douleur, urgences), 30029, Nîmes cedex, France
| | - Gauthier Mathon
- Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Service de Réanimation, 69310, Pierre-Bénite, France
| | - Charlotte Arbelot
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Nord Hospital, Marseille, France
| | - Mohamed Boucekine
- Centre d'Etudes et de Recherches Sur Les Services de Santé et Qualité, Faculté de Médecine, Aix-Marseille université, Marseille, France
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Nord Hospital, Marseille, France
| | - Laurent Zieleskiewicz
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Nord Hospital, Marseille, France
- Center for Cardiovascular and Nutrition Research (C2VN), Aix Marseille University, INSERM, INRA, Marseille, France
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Bronshteyn YS, Anderson TA, Badakhsh O, Boublik J, Brady MBW, Charnin JE, Coker BJ, Deriy LB, Hardman HD, Haskins SC, Hollon M, Hsia HLJ, Neelankavil JP, Panzer OPF, Perlas A, Ramsingh D, Sharma A, Shore-Lesserson LJ, Zimmerman JM. Diagnostic Point-of-Care Ultrasound: Recommendations From an Expert Panel. J Cardiothorac Vasc Anesth 2021; 36:22-29. [PMID: 34059438 DOI: 10.1053/j.jvca.2021.04.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/28/2021] [Accepted: 04/10/2021] [Indexed: 12/31/2022]
Abstract
Diagnostic point-of-care ultrasound (PoCUS) has emerged as a powerful tool to help anesthesiologists guide patient care in both the perioperative setting and the subspecialty arenas. Although anesthesiologists can turn to guideline statements pertaining to other aspects of ultrasound use, to date there remains little in the way of published guidance regarding diagnostic PoCUS. To this end, in 2018, the American Society of Anesthesiologists chartered an ad hoc committee consisting of 23 American Society of Anesthesiologists members to provide recommendations on this topic. The ad hoc committee convened and developed a committee work product. This work product was updated in 2021 by an expert panel of the ad hoc committee to produce the document presented herein. The document, which represents the consensus opinion of a group of practicing anesthesiologists with established expertise in diagnostic ultrasound, addresses the following issues: (1) affirms the practice of diagnostic PoCUS by adequately trained anesthesiologists, (2) identifies the scope of practice of diagnostic PoCUS relevant to anesthesiologists, (3) suggests the minimum level of training needed to achieve competence, (4) provides recommendations for how diagnostic PoCUS can be used safely and ethically, and (5) provides broad guidance about diagnostic ultrasound billing.
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Affiliation(s)
- Yuriy S Bronshteyn
- Duke University School of Medicine, Duke University Health System, Durham Veterans Health Administration, Durham, NC.
| | | | - Orode Badakhsh
- University of California Davis Medical Center, Sacramento, CA
| | - Jan Boublik
- Stanford University School of Medicine, Stanford, CA
| | | | - Jonathan E Charnin
- Mayo Clinic, Rochester, MN, University of Alabama at Birmingham, Birmingham, AL
| | - Bradley J Coker
- Mayo Clinic, Rochester, MN, University of Alabama at Birmingham, Birmingham, AL
| | - Lev B Deriy
- Department of Anesthesiology and Critical Care, University of New Mexico, Albuquerque, NM
| | - H David Hardman
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stephen C Haskins
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill-Cornell Medical College, New York, NY
| | - McKenzie Hollon
- Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Hung-Lun John Hsia
- Duke University School of Medicine, Duke University Health System, Durham Veterans Health Administration, Durham, NC
| | | | - Oliver P F Panzer
- Columbia University College of Physicians and Surgeons, New York, NY
| | - Anahi Perlas
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Davinder Ramsingh
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA
| | - Archit Sharma
- University of Iowa Carver College of Medicine, Iowa City, IA
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Assessing Competence in Critical Care Echocardiography: Development and Initial Results of an Examination and Certification Processes. Crit Care Med 2021; 49:1285-1292. [PMID: 33730745 DOI: 10.1097/ccm.0000000000004940] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the development and initial results of an examination and certification process assessing competence in critical care echocardiography. DESIGN A test writing committee of content experts from eight professional societies invested in critical care echocardiography was convened, with the Executive Director representing the National Board of Echocardiography. Using an examination content outline, the writing committee was assigned topics relevant to their areas of expertise. The examination items underwent extensive review, editing, and discussion in several face-to-face meetings supervised by National Board of Medical Examiners editors and psychometricians. A separate certification committee was tasked with establishing criteria required to achieve National Board of Echocardiography certification in critical care echocardiography through detailed review of required supporting material submitted by candidates seeking to fulfill these criteria. SETTING The writing committee met twice a year in person at the National Board of Medical Examiner office in Philadelphia, PA. SUBJECTS Physicians enrolled in the examination of Special Competence in Critical Care Electrocardiography (CCEeXAM). MEASUREMENTS AND MAIN RESULTS A total of 524 physicians sat for the examination, and 426 (81.3%) achieved a passing score. Of the examinees, 41% were anesthesiology trained, 33.2% had pulmonary/critical care background, and the majority had graduated training within the 10 years (91.6%). Most candidates work full-time at an academic hospital (46.9%). CONCLUSIONS The CCEeXAM is designed to assess a knowledge base that is shared with echocardiologists in addition to that which is unique to critical care. The National Board of Echocardiography certification establishes that the physician has achieved the ability to independently perform and interpret critical care echocardiography at a standard recognized by critical care professional societies encompassing a wide spectrum of backgrounds. The interest shown and the success achieved on the CCEeXAM by practitioners of critical care echocardiography support the standards set by the National Board of Echocardiography for testamur status and certification in this imaging specialty area.
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Vives M, Hernández A, González AD, Torres J, Cuesta P, Villen T, Carmona P, Nagore D, Serna M, Bengoetxea U, Borrat X, García de Casasola G, Sánchez E, Campo R, Mercadal J. Diploma on Ultrasound training and competency for Intensive Care and Emergency Medicine: Consensus document of the Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:143-148. [PMID: 33172655 DOI: 10.1016/j.redar.2020.06.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 06/11/2023]
Abstract
The use of ultrasound as a clinical diagnostic tool and guide of bedside procedures has become an indispensable examination in the acute critically ill patient. The training of professionals in minimum skills of knowledge, management and indications of use of ultrasound required to be defined by the Scientific Societies. The Intensive Care Ultrasound Working Group of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), of the Spanish Society of Internal Medicine (SEMI) and the Spanish Society of Emergency Medicine (SEMES) has developed this consensus document in which the recommended training program and the minimum competencies to be achieved with regard to the use of Ultrasound in Intensive Care, Anesthesia and Emergency medicine are defined. This document defines the training program and the skills to acquire in order to achieve the diploma in lung, abdominal and vascular ultrasound. This document can serve as a guide to define the skills to be acquired in the training programs of residents (MIRs) of specialists working in intensive care, anesthesia, and emergency medicine.
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Affiliation(s)
- M Vives
- Co-director del grupo de trabajo de Ecografía Clínica en Cuidados Intensivos de la SEDAR; Servicio de Anestesia y Reanimación, Hospital Universitario de Girona Dr. J. Trueta. Universidad de Girona, Girona, España.
| | - A Hernández
- Servicio de Anestesia y Reanimación, Grupo Policlínica, Ibiza, España
| | - A D González
- Servicio de Anestesia y Reanimación, Clínica Universidad de Navarra, Pamplona, España
| | - J Torres
- Servicio de Medicina Interna, Hospital Universitario Infanta Cristina Parla, Madrid, España; Co-director del grupo de trabajo de Ecografía Clínica de la SEMI
| | - P Cuesta
- Servicio de Anestesia y Reanimación, Hospital Universitario de Albacete, Albacete, España
| | - T Villen
- Servicio de Urgencias, Hospital Universitario La Paz, Madrid, España; Director del grupo de trabajo de Ecografía Clínica de la SEMES
| | - P Carmona
- Servicio de Anestesia y Reanimación, Hospital Universitario La Fe, Valencia, España
| | - D Nagore
- Department of Anaesthesia & Intensive Care, Barts Heart Center. Barts Health NHS Trust, London, Reino Unido
| | - M Serna
- Servicio de Anestesia y Reanimación, Hospital Universitario de Denia, Denia, Alicante, España
| | - U Bengoetxea
- Servicio de Anestesia y Reanimación, Hospital de Urduliz, Bilbao, España
| | - X Borrat
- Servicio de Anestesia y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
| | - G García de Casasola
- Servicio de Medicina Interna, Hospital Universitario Infanta Cristina. Parla, Madrid, España; Co-director del grupo de trabajo de Ecografía Clínica de la SEMI
| | - E Sánchez
- Servicio de Anestesia y Reanimación, Hospital Gregorio Marañón, Madrid, España
| | - R Campo
- Servicio de Urgencias, Hospital Santa Bárbara de Puertollano, Ciudad Real, España
| | - J Mercadal
- Co-director del grupo de trabajo de Ecografía Clínica en Cuidados Intensivos de la SEDAR; Servicio de Anestesia y Reanimación, Hospital Clinic de Barcelona, Barcelona, España
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Wang Y, Qian J, Qian S, Liu C, Chen Y, Lu G, Zhang Y, Ren X. An email-based survey of practice regarding hemodynamic monitoring and management in children with septic shock in China. Transl Pediatr 2021; 10:587-597. [PMID: 33850817 PMCID: PMC8039781 DOI: 10.21037/tp-20-374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Understanding current hemodynamic monitoring (HM) practice patterns is essential to determine education and training strategies in China. The survey was to describe the practice of HM and management in children with septic shock in China. METHODS We conducted an Email-based survey of members of sub-association of pediatric intensive care physicians. The questionnaire consisted of 22 questions and gathered the following information: (I) general information on the hospitals, respective ICUs and participants, (II) the availability of technical equipment and parameters of HM and (III) management simulation of septic shock in three clinical case vignettes. RESULTS Surveys were received from 68 institutions (87.2%) and 368 questionnaires (response-rate 45.1%) were included. Basic HM (93-100%) were reported as the most utilized parameters, followed by advanced HM which included central venous pressure (CVP) (56.0%), cardiac output (53.5%), and central venous oxygen saturation (36.7%), 61.1% (225/368) of respondents stated the utilization of non-invasive HM equipment. The factors such as ICU specialist training center (P=0.003) and more than 30 cases of septic shock per year (P=0.002) were related to the utilization of non-invasive monitoring equipment. In the simulated case vignette, 49.7% (183/368) of respondents reported performing fluid responsiveness and volume status (FR-VS) assessment. Despite differences in training centers (P=0.005) and educational backgrounds (P=0.030), FR-VS assessment was not related to the volume expansion decision. CONCLUSIONS There is a large variability in use advanced HM parameters, an increasing awareness and acceptance of non-invasive HM devices and a potential need for hemodynamic education and training in pediatric intensive care medicine in China.
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Affiliation(s)
- Ying Wang
- Pediatric Intensive Care Unit, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Juan Qian
- Pediatric Intensive Care Unit, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Suyun Qian
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Chunfeng Liu
- Pediatric Intensive Care Unit, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yibing Chen
- Pediatric Intensive Care Unit, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Guoping Lu
- Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Yucai Zhang
- Pediatric Intensive Care Unit, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xiaoxu Ren
- Pediatric Intensive Care Unit, Children's Hospital affiliated to Capital Institute of Pediatrics, Beijing, China
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Sanfilippo F, La Rosa V, Grasso C, Santonocito C, Minardi C, Oliveri F, Iacobelli R, Astuto M. Echocardiographic Parameters and Mortality in Pediatric Sepsis: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2021; 22:251-261. [PMID: 33264235 DOI: 10.1097/pcc.0000000000002622] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We conducted a systematic review and meta-analysis to investigate the prognostic value of echocardiographic parameters in pediatric septic patients. DATA SOURCES MEDLINE, PubMed, and EMBASE (last update April 5, 2020). STUDY SELECTION Observational studies of pediatric sepsis providing echocardiographic parameters in relation to mortality. DATA EXTRACTION Echocardiography data were categorized as those describing left ventricular systolic or diastolic function, right ventricular function, and strain echocardiography parameters. Data from neonates and children were considered separately. Analysis is reported as standardized mean difference and 95% CI. DATA SYNTHESIS We included data from 14 articles (n = 5 neonates, n = 9 children). The fractional shortening was the most commonly reported variable (11 studies, n = 555 patients) and we did not identify an association with mortality (standardized mean difference 0.22, 95% CI [-0.02 to 0.47]; p = 0.07, I2 = 28%). In addition, we did not find any association with mortality also for left ventricular ejection fraction (nine studies, n = 417; standardized mean difference 0.06, 95% CI [-0.27 to 0.40]; p = 0.72, I2 = 51%), peak velocity of systolic mitral annular motion determined by tissue Doppler imaging wave (four studies, n = 178; standardized mean difference -0.01, 95% CI [-0.34 to 0.33]; p = 0.97, I2 = 0%), and myocardial performance index (five studies, n = 219; standardized mean difference -0.51, 95% CI [-1.10 to 0.08]; p = 0.09, I2 = 63%). However, in regard to left ventricular diastolic function, there was an association with mortality for higher early wave of transmitral flow/peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging ratio (four studies, n = 189, standardized mean difference -0.45, 95% CI [-0.80 to -0.10]; p = 0.01, I2 = 0%) or lower peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging wave (three studies, n = 159; standardized mean difference 0.49, 95% CI [0.13-0.85]; p = 0.008, I2 = 0%). We did not find any association with mortality for early wave of transmitral flow/late (atrial) wave of trans-mitral flow ratio (six studies, n = 273; standardized mean difference 0.28, 95% CI [-0.42 to 0.99]; p = 0.43, I2 = 81%) and peak velocity of systolic mitral annular motion determined by tissue Doppler imaging wave measured at the tricuspid annulus (three studies, n = 148; standardized mean difference -0.18, 95% CI [-0.53 to 0.17]; p = 0.32, I2 = 0%). Only a few studies were conducted with strain echocardiography. CONCLUSIONS This meta-analysis of echocardiography parameters in pediatric sepsis failed to find any association between the measures of left ventricular systolic or right ventricular function and mortality. However, mortality was associated with higher early wave of transmitral flow/peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging or lower peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging, indicating possible importance of left ventricular diastolic dysfunction. These are preliminary findings because of high clinical heterogeneity in the studies to date.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele," Catania, Italy
| | - Valeria La Rosa
- School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico," University of Catania, Catania, Italy
| | - Chiara Grasso
- School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico," University of Catania, Catania, Italy
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele," Catania, Italy
| | - Carmelo Minardi
- Department of Anesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele," Catania, Italy
| | - Francesco Oliveri
- Department of Anesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele," Catania, Italy
| | - Roberta Iacobelli
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Cardiology Unit, Bambino Gesu' Hospital, Rome, Italy
| | - Marinella Astuto
- Department of Anesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele," Catania, Italy
- School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico," University of Catania, Catania, Italy
- Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
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