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Echocardiography in Hemodynamic Monitoring FREE TO VIEW

Loïc Chimot, MD; Matthieu Legrand, MD; Emmanuel Canet, MD; Virginie Lemiale, MD; Elie Azoulay, MD, PhD
Author and Funding Information

From the Saint-Louis Hospital, Assistance Publique-Hopitaux de Paris, University of Paris.

Correspondence to: Loïc Chimot, MD, Medical Intensive Care Unit, 1 avenue Claude Vellefaux, 75010, Paris, France; e-mail:loic.chimot@neuf.fr


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(2):501-502. doi:10.1378/chest.09-1794
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To the Editor:

Although interest in ultrasound-based techniques has emerged during the last few years, echocardiography still remains largely not used, or under used, in many ICUs. Basic echocardiography can indeed identify critical echocardiographic patterns in critically ill patients.1 Early diagnoses of acute pulmonary embolism, myocardial infarction with accompanying complications (cardiac tamponade, wall rupture, valvular regurgitation), or aortic injuries are possible examples. In patients with shock, echocardiography should then be used to guide therapy. Evaluating cardiac output, assessing preload responsiveness and right and left ventricular systolic functions, and detecting a patent foramen ovale should be considered as the standard of care in patients with shock.

Because echocardiography is available at bedside, this easy-to-use, easy-to-learn, noninvasive instrument offers a quick and timely assessment of hemodynamic status.2,3 Moreover, follow-up measures can be obtained after any intervention (eg, fluids, vasoactive drugs, or thrombolysis).

For example, in our ICU, we recently had a case that perfectly illustrates the value of bedside echocardiography in the management of patients with shock. A 59-year-old woman with a medical history of multiple sclerosis with paraplegia and depression was admitted in a psychiatric center after trying to commit suicide. Five days after admission, fever led to the diagnosis of urinary tract infection with left-sided back pain, a high leukocyte count, and Escherichia coli in a urine culture. She was then transferred to the ICU with a diagnosis of shock (eg, marbling, mean arterial pressure of 44 mm Hg, heart rate of 150/min). Multiple organ failure rapidly developed, with the need for mechanical ventilation, fluid loading, norepinephrine infusion (1.5μ/kg/m), and renal replacement therapy. Laboratory examination showed a high leukocyte count (21,000/mm3), lactic acidosis (pH 7.10, arterial lactate 6.4 mmol/L), acute renal failure (anuria), and mild hypoxemia (Pao2/Fio2 = 300). Hepatic and pancreatic tests were normal. An abdominal CT scan showed diffuse colitis with no sign of perforation and lack of kidney abnormality. The diagnosis of septic shock was suggested, and wide spectrum antibiotics were initiated. Upon hemodynamic optimization, transesophageal echocardiography was performed to assess cardiac function because of the patient’s unstable state, with persistent lactacidemia despite fluids and vasopressors. An unexpected image of acute core pulmonale was found, with right ventricular dilation, a paradoxical interventricular septal motion pattern, and no respiratory variation of the superior vena cava diameter with a massive mobile thrombus in the right atrium (Fig 1 and online video supplement), confirming the diagnosis of massive pulmonary embolism. Extension of the thrombus to the right pulmonary artery was seen. Thrombolysis was subsequently implemented, leading to a decrease in vasopressors and the disappearance of thrombus from the right atrium on the follow-up by echocardiography.

Figure Jump LinkFigure 1. Four cavities view with transesophageal echocardiography showing a massive thrombus in the right atrium (arrow). RA = right atrium; RV = right ventricle; LA = left atrium; LV = left ventricle. See online video supplement.Grahic Jump Location

This case report illustrates why echocardiography should be considered as a major tool in the early hemodynamic assessment of patients with shock. Along this line, basic and advanced training programs for ICU clinicians to provide skills, master competence, and develop professionalism in echocardiography should be encouraged.4

Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW. Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest. 2009;1356:1416-1420. [CrossRef] [PubMed]
 
Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;1354:1050-1060. [CrossRef] [PubMed]
 
Kaplan A, Mayo PH. Echocardiography performed by the pulmo nary/critical care medicine physician. Chest. 2009;1352:529-535. [CrossRef] [PubMed]
 
Schmidt GA. ICU ultrasound. The coming boom. Chest. 2009;1356:1407-1408. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Four cavities view with transesophageal echocardiography showing a massive thrombus in the right atrium (arrow). RA = right atrium; RV = right ventricle; LA = left atrium; LV = left ventricle. See online video supplement.Grahic Jump Location

Tables

References

Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW. Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest. 2009;1356:1416-1420. [CrossRef] [PubMed]
 
Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;1354:1050-1060. [CrossRef] [PubMed]
 
Kaplan A, Mayo PH. Echocardiography performed by the pulmo nary/critical care medicine physician. Chest. 2009;1352:529-535. [CrossRef] [PubMed]
 
Schmidt GA. ICU ultrasound. The coming boom. Chest. 2009;1356:1407-1408. [CrossRef] [PubMed]
 
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