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Berger D, Werner Moller P, Bachmann KF. Cardiopulmonary interactions-which monitoring tools to use? Front Physiol 2023; 14:1234915. [PMID: 37621761 PMCID: PMC10445648 DOI: 10.3389/fphys.2023.1234915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/18/2023] [Indexed: 08/26/2023] Open
Abstract
Heart-lung interactions occur due to the mechanical influence of intrathoracic pressure and lung volume changes on cardiac and circulatory function. These interactions manifest as respiratory fluctuations in venous, pulmonary, and arterial pressures, potentially affecting stroke volume. In the context of functional hemodynamic monitoring, pulse or stroke volume variation (pulse pressure variation or stroke volume variability) are commonly employed to assess volume or preload responsiveness. However, correct interpretation of these parameters requires a comprehensive understanding of the physiological factors that determine pulse pressure and stroke volume. These factors include pleural pressure, venous return, pulmonary vessel function, lung mechanics, gas exchange, and specific cardiac factors. A comprehensive knowledge of heart-lung physiology is vital to avoid clinical misjudgments, particularly in cases of right ventricular (RV) failure or diastolic dysfunction. Therefore, when selecting monitoring devices or technologies, these factors must be considered. Invasive arterial pressure measurements of variations in breath-to-breath pressure swings are commonly used to monitor heart-lung interactions. Echocardiography or pulmonary artery catheters are valuable tools for differentiating preload responsiveness from right ventricular failure, while changes in diastolic function should be assessed alongside alterations in airway or pleural pressure, which can be approximated by esophageal pressure. In complex clinical scenarios like ARDS, combined forms of shock or right heart failure, additional information on gas exchange and pulmonary mechanics aids in the interpretation of heart-lung interactions. This review aims to describe monitoring techniques that provide clinicians with an integrative understanding of a patient's condition, enabling accurate assessment and patient care.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
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Zhao H, Yan Y, Liu Y, Long L, Xue H, Zhao H. Bedside critical ultrasound as a key to the diagnosis of obstructive atelectasis complicated with acute cor pulmonale and differentiation from pulmonary embolism: A case report. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:611-617. [PMID: 35285521 PMCID: PMC9310774 DOI: 10.1002/jcu.23190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 06/14/2023]
Abstract
Acute attack of dyspnea may be combined with acute cor pulmonale (ACP). Rapid and accurate identification of the etiology of ACP is the key to its diagnosis and treatment. Echocardiography is a better imaging tool in the assessment of right ventricular function. Under the guidance of the theory of cardiopulmonary interaction, ultrasonography can detect lung lesions, which causes ACP. We report the case of a 67-year-old man who received mechanical ventilation for acute respiratory failure. Right ventricular dysfunction was detected by echocardiography. Lung ultrasound showed a high risk of pulmonary embolism. However, obstructive atelectasis should not be ruled out after increasing back area ultrasonography. To avoid pitfalls, combined cardiac and lung ultrasound should be used carefully and strictly.
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Affiliation(s)
- Haotian Zhao
- Department of UltrasoundHebei General HospitalShijiazhuangHebeiChina
| | - Yaru Yan
- Department of UltrasoundShijiazhuang People's HospitalShijiazhuangHebeiChina
| | - Yi Liu
- Department of UltrasoundHebei General HospitalShijiazhuangHebeiChina
| | - Ling Long
- Department of Intensive Care UnitHebei General HospitalShijiazhuangHebeiChina
| | - Hongyuan Xue
- Department of UltrasoundHebei General HospitalShijiazhuangHebeiChina
| | - Heling Zhao
- Department of Intensive Care UnitHebei General HospitalShijiazhuangHebeiChina
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Liu Z, Li Y, Zhao X, Ge L, Zhu G, Hong P, Tang S, Zhang S, Tian X, Wang S, Liu C, Zhang H, Ma L. Renal cell carcinoma with tumor thrombus growing against the direction of venous return: an indicator of complicated surgery and poor prognosis. BMC Surg 2021; 21:443. [PMID: 34963464 PMCID: PMC8713414 DOI: 10.1186/s12893-021-01448-0] [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] [Received: 04/12/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To explore the effect of tumor thrombus growing against the direction of venous return (GADVR) tumor thrombus on the choice of surgical approach, the impact on the complexity of the surgery and the prognosis. METHODS We retrospectively analyzed the clinicopathological data of 213 patients, who underwent surgery in a single center of Peking University Third Hospital between January 2016 and June 2020. For right renal cell carcinoma (RCC) and venous tumor thrombus (VTT), imaging revealed a filling defect in the left renal vein, which was significantly enhanced in enhanced imaging, suggesting that the tumor thrombus grew against the direction of venous return into the left renal vein. For left RCC and VTT, at least one of the left renal vein branches has tumor thrombus. The branches include the left adrenal vein, the left gonadal vein (testicular vein or ovarian vein), and the left ascending lumbar vein. The patients were divided into two groups according to whether they were GADVR tumor thrombus, and we compare the clinicopathological characteristics of GADVR tumor thrombus and non-GADVR tumor thrombus. Univariate and multivariate Cox regression analyses were performed to explore the risk factors that affect the prognosis of patients with RCC and VTT. Kaplan-Meier plots were conducted to evaluate the effect of GADVR on progression-free survival (PFS). RESULTS Compared with non-GADVR tumor thrombus, patients with GADVR tumor thrombus had a higher proportion of open surgery (76.2% vs. 52.1%, P = 0.035), a higher proportion of tumor thrombus adhering to the inferior vena cava (IVC) vessel wall (81% vs. 45.8%, P = 0.002), a higher proportion of segmental resection of the IVC vessel wall (61.9% vs. 15.6%, P < 0.001); higher preoperative serum creatinine value (110.0 μmol/L vs. 91.0 μmol/L, P = 0.015), a higher proportion of tumor thrombus combined with bland thrombus (non-tumor thrombus) (57.1% vs. 19.8%, P < 0.001). In terms of surgical complexity, patients with GADVR tumor thrombus had a longer median operation time (379 min vs. 308 min, P = 0.038), more median surgical blood loss (1400 mL vs. 600 mL, P = 0.018), and more postoperative complications (52.4% vs. 30.7%, P = 0.045). Multivariate Cox regression analysis showed that GADVR tumor thrombus, symptoms, postoperative serum creatinine, distant metastasis, sarcomatoid feature, pathological type, lymph node dissection were independent risk factors for PFS. Patients with GADVR tumor thrombus's median survival time was 14.0 months, while patients with non-GADVR tumor thrombus were 32.0 months (P = 0.016). GADVR tumor thrombus is an independent risk factor for PFS in patients with RCC and VTT. CONCLUSION GADVR tumor thrombus is a characteristic feature of tumor thrombus, with an incidence of 9.9%. It has a higher proportion of open surgery and higher surgical complexity, which is an independent risk factor for PFS.
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Affiliation(s)
- Zhuo Liu
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Yuxuan Li
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Xun Zhao
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Guodong Zhu
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Peng Hong
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Shiying Tang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Xiaojun Tian
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Shumin Wang
- Department of Ultrasound, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.
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Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine. Intensive Care Med 2021; 47:1347-1367. [PMID: 34787687 PMCID: PMC8596353 DOI: 10.1007/s00134-021-06486-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/16/2021] [Indexed: 01/21/2023]
Abstract
Purpose To provide consensus, and a list of experts’ recommendations regarding the basic skills for head-to-toe ultrasonography in the intensive care setting. Methods The Executive Committee of the European Society of Intensive Care (ESICM) commissioned the project and supervised the methodology and structure of the consensus. We selected an international panel of 19 expert clinicians–researchers in intensive care unit (ICU) with expertise in critical care ultrasonography (US), plus a non-voting methodologist. The panel was divided into five subgroups (brain, lung, heart, abdomen and vascular ultrasound) which identified the domains and generated a list of questions to be addressed by the panel. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Statements were classified as a strong recommendation (84% of agreement), weak recommendation (74% of agreement), and no recommendation (less than 74%), in favor or against. Results This consensus produced a total of 74 statements (7 for brain, 20 for lung, 20 for heart, 20 for abdomen, 7 for vascular Ultrasound). We obtained strong agreement in favor for 49 statements (66.2%), 8 weak in favor (10.8%), 3 weak against (4.1%), and no consensus in 14 cases (19.9%). In most cases when consensus was not obtained, it was felt that the skills were considered as too advanced. A research agenda and discussion on training programs were implemented from the results of the consensus. Conclusions This consensus provides guidance for the basic use of critical care US and paves the way for the development of training and research projects. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06486-z.
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Guarracino F, Vetrugno L, Forfori F, Corradi F, Orso D, Bertini P, Ortalda A, Federici N, Copetti R, Bove T. Lung, Heart, Vascular, and Diaphragm Ultrasound Examination of COVID-19 Patients: A Comprehensive Approach. J Cardiothorac Vasc Anesth 2021; 35:1866-1874. [PMID: 32624431 PMCID: PMC7289113 DOI: 10.1053/j.jvca.2020.06.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023]
Abstract
Lung ultrasound (LU) has a multitude of features and capacities that make it a useful medical tool to assist physicians contending with the pandemic spread of novel coronavirus disease-2019 (COVID-19) caused by coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thus, an LU approach to patients with suspected COVID-19 is being implemented worldwide. In noncritical COVID-19 patients, 2 new LU signs have been described and proposed, the "waterfall" and the "light beam" signs. Both signs have been hypothesized to increase the diagnostic accuracy of LU for COVID-19 interstitial pneumonia. In critically ill patients, a distinct pattern of LU changes seems to follow the disease's progression, and this information can be used to guide decisions about when a patient needs to be ventilated, as occurs in other disease states similar to COVID-19. Furthermore, a new algorithm has been published, which enables the automatic detection of B-lines as well as quantification of the percentage of the pleural line associated with lung disease. In COVID-19 patients, a direct involvement of cardiac function has been demonstrated, and ventilator-induced diaphragm dysfunction might be present due to the prolonged mechanical ventilation often involved, as reported for similar diseases. For this reason, cardiac and diaphragm ultrasound evaluation are highly important. Last but not least, due to the thrombotic tendency of COVID-19 patients, particular attention also should be paid to vascular ultrasound. This review is primarily devoted to the study of LU in COVID-19 patients. The authors explain the significance of its "light and shadows," bearing in mind the context in which LU is being used-the emergency department and the intensive care setting. The use of cardiac, vascular, and diaphragm ultrasound is also discussed, as a comprehensive approach to patient care.
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Affiliation(s)
- Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Luigi Vetrugno
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy; Department of Anesthesia and Intensive care, University-Hospital of Udine, Italy, Udine, Italy.
| | - Francesco Forfori
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy; Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Corradi
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy; Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Daniele Orso
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy; Department of Anesthesia and Intensive care, University-Hospital of Udine, Italy, Udine, Italy
| | - Pietro Bertini
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Federici
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy; Department of Anesthesia and Intensive care, University-Hospital of Udine, Italy, Udine, Italy
| | - Roberto Copetti
- Emergency Department, Azienda Sanitaria Universitaria Friuli Centrale, Latisana General Hospital, Latisana, Italy
| | - Tiziana Bove
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy; Department of Anesthesia and Intensive care, University-Hospital of Udine, Italy, Udine, Italy
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Rajendram R, Hussain A, Mahmood N, Kharal M. Feasibility of using a handheld ultrasound device to detect and characterize shunt and deep vein thrombosis in patients with COVID-19: an observational study. Ultrasound J 2020; 12:49. [PMID: 33252722 PMCID: PMC7702202 DOI: 10.1186/s13089-020-00197-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/17/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) causes an atypical acute respiratory distress syndrome associated with thromboembolism and high shunt fraction. Shunt may be intrapulmonary, or extrapulmonary. Handheld devices are increasingly being used for point-of-care ultrasound, but their use to characterize shunt has not been reported. OBJECTIVES Determine the feasibility of using handheld ultrasound to detect and characterize anatomical substrates of hypoxia and deep vein thrombosis (DVT) in patients with COVID-19 suspected to have severe shunt. METHODS A handheld ultrasound device (iQ, Butterfly, USA) was used to perform lung ultrasound, vascular assessment for DVT, and limited transthoracic echocardiography (TTE) with color Doppler and saline microbubble contrast in patients with COVID-19 suspected to have severe shunt. Images were reassessed by an independent reviewer. RESULTS After screening 40 patients, six patients who fulfilled the inclusion criteria were identified. Two were excluded because palliation had been initiated. So, four patients were studied. Interpretable images were obtained in all cases. Interobserver agreement was good. All patients had abnormal lung ultrasound (lung ultrasound score range 17-22). Identified lung pathology included interstitial syndrome with light beams and small peripheral consolidation (4), lobar consolidation (1), and pleural effusion (1). Abnormal echocardiographic findings included interatrial shunt (2), intrapulmonary shunt (1), and dilated right ventricle with tricuspid valve regurgitation (1). Significant DVT was not detected. CONCLUSION Use of handheld ultrasound to perform combined lung ultrasound, DVT ultrasound, and limited TTE with color Doppler and saline microbubble contrast is feasible, and may be able to characterize shunt in critically hypoxic patients. Serial studies could be used to monitor changes in shunt. Further studies are required to determine whether this can guide treatment to improve the outcomes of patients with refractory hypoxia.
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Affiliation(s)
- Rajkumar Rajendram
- Department of Medicine, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia.
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Arif Hussain
- Department of Cardiac Sciences, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Naveed Mahmood
- Department of Medicine, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mubashar Kharal
- Department of Medicine, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Aubry A, Paternot A, Vieillard-Baron A. [Cor pulmonale]. Rev Mal Respir 2020; 37:257-266. [PMID: 32088063 DOI: 10.1016/j.rmr.2019.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 10/15/2019] [Indexed: 11/19/2022]
Abstract
Cor pulmonale is a disease of the heart characterised by dilatation of the right ventricle and paradoxical movement of the interventricular septum. The diagnosis depends on echocardiography even if pulmonary artery catheterisation suggests it. It is secondary to pulmonary disease or a disorder of the pulmonary circulation. These two mechanisms, which are often connected, involve pulmonary hypertension as the origin of a systolic and diastolic overload of the right ventricle, which then leads to the alterations of its structure and performance. Acute cor pulmonale is usually secondary to an acute respiratory distress syndrome or to a pulmonary embolism but it can also be seen in primary lactic acidosis, a vaso-occlusive crisis in a patient with sickle cell anaemia, severe acute asthma, and entry of air or injected crushed tablets into the circulation. Chronic cor pulmonale is the terminal stage of pulmonary hypertension. Clinically these patients are dyspnoeic with signs of chronic right heart failure. They should have an echocardiogram confirming the cardiac involvement. Certain precipitating factors, such as infection of any origin, have been reported, leading to acute on chronic cor pulmonale that has a particularly high mortality.
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Affiliation(s)
- A Aubry
- Réanimation médico-chirurgicale, pôle thorax-vaisseaux-abdomen-métabolisme, hôpital universitaire Ambroise-Paré, Assistance publique-Hôpitaux de Paris, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France; Faculté de médecine Paris Île-de-France Ouest, université de Versailles-Saint-Quentin-en-Yvelines, 78280 Saint-Quentin-en-Yvelines, France
| | - A Paternot
- Réanimation médico-chirurgicale, pôle thorax-vaisseaux-abdomen-métabolisme, hôpital universitaire Ambroise-Paré, Assistance publique-Hôpitaux de Paris, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France; Faculté de médecine Paris Île-de-France Ouest, université de Versailles-Saint-Quentin-en-Yvelines, 78280 Saint-Quentin-en-Yvelines, France
| | - A Vieillard-Baron
- Réanimation médico-chirurgicale, pôle thorax-vaisseaux-abdomen-métabolisme, hôpital universitaire Ambroise-Paré, Assistance publique-Hôpitaux de Paris, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France; Faculté de médecine Paris Île-de-France Ouest, université de Versailles-Saint-Quentin-en-Yvelines, 78280 Saint-Quentin-en-Yvelines, France; INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, 94807 Villejuif, France.
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Vieillard-Baron A, Millington SJ, Sanfilippo F, Chew M, Diaz-Gomez J, McLean A, Pinsky MR, Pulido J, Mayo P, Fletcher N. A decade of progress in critical care echocardiography: a narrative review. Intensive Care Med 2019; 45:770-788. [DOI: 10.1007/s00134-019-05604-2] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
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