1. Echocardiography in ICU Michel Slama AmiensFrance LEVEL 1 basic LEVEL 2: advanced

2. How to use echocardiography in ICU patients  Two clinical situations  Unexplained shock  Unexplained respiratory failure

3. How to use echocardiography in ICU patients  Two clinical situations  Unexplained shock  Unexplained respiratory failure

4. Step 1: rule out péricardial tamponnade Step 1: rule out péricardial tamponnade

5. LEVEL 1 goal directed

6. Step 2 : evaluation of fluid responsiveness

7. Mean 211 / 195 52 % CHEST 2002, 121:2000-8 R / NRR (%) Calvin (Surgery 81) 20 / 871 % Calvin (Surgery 81) 20 / 871 % Schneider (Am Heart J 88) 13 / 572 % Schneider (Am Heart J 88) 13 / 572 % Reuse (Chest 90) 26 / 1563 % Reuse (Chest 90) 26 / 1563 % Magder (J Crit Care 92) 17 / 1652 % Magder (J Crit Care 92) 17 / 1652 % Diebel (Arch Surgery 92) 13 / 959 % Diebel (Arch Surgery 92) 13 / 959 % Diebel (J Trauma 94) 26 / 3940 % Diebel (J Trauma 94) 26 / 3940 % Wagner (Chest 98) 20 / 1656 % Wagner (Chest 98) 20 / 1656 % Tavernier (Anesthesio 98) 21 / 1460 % Tavernier (Anesthesio 98) 21 / 1460 % Magder (J Crit Care 99) 13 / 1645 % Magder (J Crit Care 99) 13 / 1645 % Tousignant (A Analg 00) 16 / 2440 % Tousignant (A Analg 00) 16 / 2440 % Michard (AJRCCM 00) 16 / 2440 % Michard (AJRCCM 00) 16 / 2440 % Feissel (Chest 01) 10 / 953 % Feissel (Chest 01) 10 / 953 %

8. CVP out…. D Osman Crit care med 2007

9. CVP out…. PAOP out… D Osman Crit care med 2007

10. LEVEL 1

11. TTE : IVC LEVEL 1

12.  IVC diameter = 22 % Cardiac output will increase by 18 % after fluid infusion expiration inspiration Feissel Intensive Care Med 2004 “The respiratory variation in inferior vena cava diameter as a guide to fluid therapy” LEVEL 1

13. TTE or TEE : aortic Pulsed Doppler flow  Delta peak > 12%  Delta VTI > 20% LEVEL 2

14. 12%

15. ∆Vpeak(%) Before fluid infusion 4 8 12 16 20 24 28 32 36 reponders non reponders Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Chest 2001; 119:867-873

16. -15 0 15 30 45 60 75 5101520253035 r 2 = 0.83 p < 0.001 Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Chest 2001; 119:867-873  Vpeak ( %) before fluid infusion Increase in CO after Fluid infusion (%)

17. Step 3 : evaluation of LV systolic function

18. LV function  Ejection fraction  Cardiac output  Left ventricular filling pressure

19. Shortening Fraction of LV Area Ejection Fraction Systolic Function LEVEL 1

20. NB Shiller, Heart, 1996;75:17-26 Estimated and measured EF LEVEL 1

21. TTE : Ejection fraction Septic shock J1 Septic shock J7

22. Pouleur, Am J Cardiol, 1983;52:813-21 Influence of afterload on EF HT, AS Septic Shock

23. How to perform echocardiographic examination in shocked patient?  Cardiac output TTE: LEVEL 2

24. How to perform echocardiographic examination in shocked patient?  Cardiac output TTE: LEVEL 2

25. E/E’ ratio predicts PAOP LEVEL 2

26. Combes A Int Care Med 2004 E/Ea ICU, mechanical ventilation LEVEL 2: advanced

27. Step 4 : assessment of right ventricular function

28. No dilatation: RVDA/LVDA< 0.6 Moderate Dilation: RVDA/LVDA 0.6 - 1 Severe dilation: RVDA/LVDA > 1 Jardin Chest 1997 DILATION VD LEVEL 1

29. RV function TAPSETDI LEVEL 2

30. Evaluation of pulmonary arterial pressures Tricuspid regurgitation Pulmonary regurgitation LEVEL 2

31. Septic Shock

32. Cardiac failure? No Acute circulatory failure Yes No Consider circulatory assistance Yes LVRV Fluid responsiveness? Fluid loading Vasopressors InotropesVasopressors* Figure 5.1-2 * LEVEL 1

33. Cardiogenic shock with pulmonary edema

34. Yes Acute circulatory failure & pulmonary venous congestion (elevated LV filling pressures) No LV systolic dysfunction? LV volume overload Extensive (anterior) AMI Mechanical complications Small AMI on previously compromised LV function Cardiogenic shock Acute myocardial infarction (AMI)? NoYes Non ischemic cardiomyopathy Fulminant myocarditis Myocardial contusion, intoxication by cardiac depressant drugs… Acute (severe) valvular regurgitation Valvular prosthesis dysfunction Volume overload (renal failure) LEVEL 1

35. Yes Acute circulatory failure & pulmonary venous congestion (elevated LV filling pressures) No LV systolic dysfunction? LV volume overload Extensive (anterior) AMI Mechanical complications Small AMI on previously compromised LV function Cardiogenic shock Acute myocardial infarction (AMI)? NoYes Non ischemic cardiomyopathy Fulminant myocarditis Myocardial contusion, intoxication by cardiac depressant drugs… Acute (severe) valvular regurgitation Valvular prosthesis dysfunction Volume overload (renal failure) Figure 5.1-3 LEVEL 1

36. Yes Acute circulatory failure & pulmonary venous congestion (elevated LV filling pressures) No LV systolic dysfunction? LV volume overload Extensive (anterior) AMI Mechanical complications Small AMI on previously compromised LV function Cardiogenic shock Acute myocardial infarction (AMI)? NoYes Non ischemic cardiomyopathy Fulminant myocarditis Myocardial contusion, intoxication by cardiac depressant drugs… Acute (severe) valvular regurgitation Valvular prosthesis dysfunction Volume overload (renal failure) Figure 5.1-3 LEVEL 1

37. Acute circulatory failure & systemic venous congestion (elevated RV filling pressures) RV dysfunction / dilatation Cardiac tamponade Relevant pulmonary hypertension? Yes*No Acute RV infarctionMassive pulmonary embolism ARDS Biventricular dysfunction (end-stage cardiomyopathy)** Figure 5.1-4 LEVEL 1

38. Acute circulatory failure & systemic venous congestion (elevated RV filling pressures) RV dysfunction / dilatation Cardiac tamponade Relevant pulmonary hypertension? Yes*No Acute RV infarctionMassive pulmonary embolism ARDS Biventricular dysfunction (end-stage cardiomyopathy)** Figure 5.1-4 LEVEL 1

39. How to use echocardiography in ICU patients  Two clinical situations  Unexplained shock  Unexplained respiratory failure

40. Respiratory failure  Two differents clinical situations :  Respiratory distress with pulmonary edema : problem is to distinghish hemodynamic pulmonary edema and ARDS or bilateral pneumonia  Severe hypoxemia without pulmonary edema: COPD, PE or intra cardiac or pulmonary shunt « White chest X-ray » « Black chest X-ray »

41. Pulmonary edema?  Question 1: is the pulmonary wedge pressure high?  Question 2: which is the cause of this pulmonary edema?

42. Pulmonary edema?  Question 1: is the pulmonary wedge pressure high?

43. PAOP is pressure into a large pulmonary vein PAOP Pulmonary artery Pulmonary Vein capillairiEscapillairiEsPAOP

44. Non invasive PAOP?

45. Mitral flow Parameters that evaluate LV relaxation preload independent E/Ea ratio LEVEL 2: advanced

46. Combes A Int Care Med 2004 E/Ea ICU, mechanical ventilation LEVEL 2: advanced

47. Pulmonary edema?  Question 2: which is the cause of this pulmonary edema?

48. Evaluation of systolic function

49. Cause of pulmonary edema Left ventricular systolic function NormalDecreased Diastolic dysfunction Valvular regurgitation or stenosis

50. Pulmonary edema Left ventricular volume (ml) End diastolic left ventricular pressure (mmHg)

52. Cause of pulmonary edema Left ventricular systolic function NormalDecreased Diastolic dysfunction Valvular regurgitation or stenosis Ischemic or non ischemic cardiomyopathy

55. Pulmonary edema and normal PAOP : ARDS bilateral pneumoniae

56. Respiratory failure  Two differents clinical situation :  Respiratory distress syndrom with pulmonary edema : problem is to distinghish between hemodynamic pulmonary edema and ARDS  Severe hypoxemia without pulmonary edema: COPD (other) or PE or intra cardiac or pulmonary shunt

57. Pulmonary embolism  Echocardiography : ACP with RV dilation, paradoxical septum mouvement and PAH.  Venous Doppler  CT Scan

58. Intra pulmonary shunt and Patent foramen ovale

60. Respiratory failure with pulmonary edema PAOP ElevatedNormal LV systolic dysfunctionNormal systolic functionARDS, pneumonia Valvular pathology Diastolic dysfunction Ischemic CM Non ischemic CM

61. Respiratory failure without pulmonary edema Contrast PositiveNegative PFOIntra pulmonary shuntPulmonary cause (COPD)

62. Case presentation