Description
The intensive care unit (ICU) is among the more important settings in which echocardiography plays a pivotal role. The ease of use, speed of execution, and completeness of information on heart anatomy and function that echocardiography is able to provide makes this tool the perfect diagnostic technique in patients for whom exhaustive information must be quickly obtained by physicians who sometimes lack specific skills in cardiovascular imaging. However, the clinical entities encountered by ICU clinicians are often difficult to distinguish and patient symptoms may not be obvious. This brief review describes three common clinical scenarios that benefit from echocardiography in the ICU, based on symptoms frequently claimed by patients admitted to the ICU. For each symptom we describe the most likely clinical possibilities, underlining the fundamental role that echocardiography plays in the differential diagnosis, and the echocardiographic elements most relevant to obtain the correct diagnosis and to guide treatment.
Résumé
- Echocardiography (echo) is a vital diagnostic tool in the ICU, medical care units, cardiac care units, cath labs, and emergency areas. It allows for rapid assessment of patients, potentially replacing stethoscopes with handheld machines enhanced by artificial intelligence, although human expertise remains crucial for optimal use.
- Echo, a short form of echocardiography, utilizes high-frequency sound waves to dynamically visualize the heart. These sound waves reflect off organs, providing real-time information about cardiac function, including ejection fraction and contractility, aiding in the detection of ischemic changes.
- The advantages of echo include its safety, reproducibility, portability, low cost, and lack of radiation exposure, making it suitable for pregnant patients. It is particularly useful in assessing patients with acute chest pain, dyspnea, hemodynamic instability, and new murmurs, as well as in guiding therapy for septic patients.
- An echo can be performed in various settings, including emergency rooms, cardiac care units, ICUs, cath labs, operating rooms, ambulances, and even bedside. Portable health units or "hospital on wheels" extend access to patients, particularly the elderly, who may not be able to visit hospitals. Top indications include chest pain, dyspnea, and hypertension.
- To prepare a patient for an echo, position them lying on their left side with arms abducted in a quiet, dark room. Hold the probe like a pen, resting your wrist on the patient's chest to maneuver the probe. Applying gel ensures good contact between the probe and the patient's skin, preventing air interference.
- There are four main types of probes: linear, curvilinear, phased array (acoprophe), and all-in-one handheld (butterfly probe). The acoprophe is designed to fit into intercostal spaces.
- Transducer movements such as tilt, sweep, rotation, slide, rocking, and angulation are essential for optimizing the image. The goal is to teach physicians basic maneuvers to identify critical signs in sick patients, rather than becoming echo experts.
- Trans-thoracic echo allows visualization of the heart's chambers, valves, and pericardium. Remember to look for signs of fluid overload in the lungs. Views include supra-sternal, parasternal, apical, sub-costal, and sub-costal IVC, with focus on the most commonly used for simple assessment.
- The parasternal long axis view requires the notch of the probe directed towards the sternum, and the view is essential for evaluating left ventricular contractility, pericardial effusions, and pleural effusions. Rotating the probe 90 degrees clockwise transitions to the short axis view, which is ideal for assessing right heart function.
- The apical 4-chamber view, with the notch oriented towards the patient's right shoulder, provides a comprehensive view of all four chambers for assessing aortic stenosis, stroke volume, cardiac index, ejection fraction, and right heart function. Sub-costal views are valuable for assessing cardiac activity, pericardial effusions, and volume status through IVC visualization.
- Basic critical care echocardiography involves assessing LV systolic function, RV size and systolic function, pericardial space for fluid, and IVC size for volume responsiveness. A critical step is also the assessment for severe left-sided regurgitation. After mastering these basic assessments, more advanced techniques can be explored.
- Key points in critical care echocardiography: every new ICU physician should be able to perform a basic CCE, hemodynamically unstable patients should receive a CCE for the initial evaluation, structured training is essential for advanced CCE training. Each ICU should have a dedicated CTE probe. All physicians should understand the advantages, pitfalls, and limitations of CTE and TEE.
Exemple de certificat
À propos des intervenants
Dr Viny Kantroo
Consultant spécialiste en pneumologie, soins intensifs et médecine du sommeil, hôpitaux Indraprastha Apollo, New Delhi, Inde
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