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EESTI ANESTESIOLOOGIDE SELTSI 17. TALVELAAGER, PYHAJÄRVE

Bodo WagnerAnestesioloog, Kesk-Soome Keskhaigla

27.-29.1.2012

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Tott. GABRIELE VIAWinfocus Echo Group

Univ. Pavia, Italy*

Doc. WOJCIECH KOSIAKDepartment of Pediatric Ultrasound & Biopsy

Medical Univ. Gdansk, Poland *




1. WHAT IS IT ABOUT CARDIOVASCULAR ECHO?

2. HOW TO APROACH TO CARDIOVASCULAR ECHO?

3. LUNG ULTRASOUND – THE IMPOSSIBLE ?

4. THE COMBINATION IN A NEW PROTOCOL




ORGAN EXPLORABILITY (%)Optic nerve 100Maxillary sinuses 100Internal jugular veins 98Subclavian veins 93Anterior lung surface 98Lateral lung surface 92Peritoneum 98Abdominal aorta 84Liver 96Gallbladder 97Right kidney 97Left kidney 100Spleen 98Pancreas 70Femoral veins 98

D. Lichtenstein, P. Biderman and G. Chironi et al

Faisabilité del' échographie générale

d'urgence en réanimationRean Urg 5 (6) 1996

+




M. Elbarbary , Lawrence A. Melniker, Giovanni Volpicelli, Luca Neri , T. Petrovic ,

E. Storti and M. BlaivasDevelopment of evidence-basedclinical recommendations and

consensus statements in criticalultrasound field: why and how?

Critical Ultrasound Journal 2010, Editorial




WHAT IT IS ? WHAT IT IS NOT ?¨ Easy to learn and to start¨ Aviavble to every

¡ anesthesist¡ intensivist¡ others

¨ 24/7¨ Eyeballing technique¨ Problem orientated¨ Bimodal questioning¨ Answer in between minutes¨ Oftenly incomplete

à Formal echo later

¨ Stupid dream of some fanatics

¨ Replacing clinical examination

¨ Replacing trad. monitoring

¨ Replacing trad. radiology

¨ Competition with cardilogy¡ Cardiologicultrasoundneeded




1. Extension of physical examination:- FEW CRUCIAL QUESTIONS

2. Limited Echo - examination:- FEW VIEWS

3. Search for biomodel answers:- YES / NO

4. Mainly qualitative/semi-quantitative:- EYEBALLING

5. Goal-directed:- DIAGNOSIS and HEMODYNAMIC MONITORING

6. Know when to refer to higher competence:- SENSE OF LIMIT G.VIA, R.BREITKREUTZ, S.PRICE, D.TALMOR,

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q JENSEN MB et al Eur J Anaesthesiol 2004 Sep§ Supportive information 35.6%§ Supplemental information 37.3%§ Dececive on the choice of therapy 24.5%

q STANKO LK et al Anaesth Intensive Care 2005 Aug§ Change of the diagnosis 29 %§ Change of the therapy 41 %

q ORME RM et al Br J Anaesth 2009 Mar§ Change of the therapy 51.2%

q MARCELINO PA et al Eur J Intern Med 2009 May§ New pathologic findings 7.5%

• important impairment of LV function 43% • important findings of valve morphology 20%

q Influence on the therapy even if PAC usedPDF created with pdfFactory trial version www.pdffactory.com



Susanna Price, Gabriele Via, Erik Sloth et al.Echocardiography practice, training and accreditation in the intensive care: document for WINFOCUS ECHO-ICU Group

Cardiovascular Ultrasound, 2008




Vignon P et al. Basic critical care echocardiography: Validation of a curriculum dedicated

to noncardiologist residents.3/2011,Vol.39, Iss.4 , 636-642

- 12 h to acquire knowledgeTheory 4 hInteractive clinic situations 2 hExpert guided ”hands on” 6 h




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PAS- (LAX+SAX)

*SC- (4CH+ICV)

X

API - 4CH




*

LAX SAX

* 4CHIVC4CH




¨ Acute cardiovascular failure§ Overall morphologic asessment§ Volume assessment+fluid responsiveness§ Pericardial collection§ LV-global function: diastolic+systolic§ RV-global function: acute cor pulmonale§ Intracardiac masses§ Gross valvular lesions§ Arterial tone




Joseph MX, Disney PJ, Da Costa R, Hutchison SJ et al.

Transthoracic echocardiography to identify orexclude cardiac cause of shock

2004 Nov;126(5):1592-7

¡ n = 100¡ “TTE image quality adequate in 99% cases”¡ “Sensitivity of TTE for cardiac cause of shock 100%”¡ “Specificity 95%”¡ “Positive predictive value 97%”¡ “Negative predictive value 100%”




Cowie BSFocused transthoracic echocardiography in the

perioperative period

2010 Sep;38(5):823-36, REVIEW

- Qualitative assessment of RV and LV function- Estimate of aortic valve gradient- RV systolic pressure- Intravascular volume status

“Transthoracic echocardiography is a valuable tool in the perioperative period and ideally the equipment and

expertise should be available in all operating rooms”




Changes in management following peri-operative focused transthoracic echo

Invasive monitoring avoided 45 (24%)Referred for formal cardiology echocardiogram 34 (20%)None 30 (18%)Fluid bolus administered 25 (15%)Invasive monitoring placed 22 (13%)Change in anaesthesia technique 20 (12%)Vasoactive drug administered 12 (7%)Postoperative recovery location altered 12 (7%)Procedure cancelled 7 (4%)Fluid restriction prescribed 3 (2%)Vasoactive drugs ceased 3 (2%)

Cowie BThree years' experience of focused cardiovascular ultrasound in the peri-operative period (n=170)

2011 Apr; 66(4):268-73




Cowie BSDoes the pulmonary artery catheter still have a role in the

perioperative period?

“...there is no clear evidence of benefit, nor harm, incardiac, intensive care or perioperative patients (of PAC*)...”

“...selected indications for the PAC may remain, suchas complex cardiac surgery or solid organ trans-plantation...”

“...however, its routine use is difficult to justify andincreasingly, most of the haemodynamic data availablefrom the PAC can be obtained less invasively with echo-cardiography...”

2011 May;39(3):345-55, REVIEW




”Fortunately thereare artifacts in

lung ultrasound”

Lichtenstein, Daniel 1997:Pulmonary echography: a method of

the future in emergency medicine and resuscitation

Rev Pneumol Clin 1997;53(2):63-8

Daniel LichtensteinService de Réanimation Médicale,

Hôpital Ambroise, Paré, Boulogne(Paris-Ouest), France

Harrison’s Principles of Internal Medicine, McGraw-Hill, 16th Edition, 2004

“...because of artifacts, caused by the air in the lungs”...”...ultrasound imaging is not useful for evaluation of the pulmonary parenchyma...”

[Article in French] No abstract available

?




1. A simple, two-dimensional apparatus is the most appropriate for lung ultrasound

2. The thorax is an area where air and water are intimately mingled

3. The lung is the largest organ in the human body4. All signs arise from the pleural line5. Lung signs are mainly based on the analysis of artifacts6. The lung is a vital organ. Most signs are dynamic7. Nearly all acute disorders of the thorax come in

contact with the surface. This explains the potential of lung ultrasound, which is paradoxical only at first view

Daniel Lichtenstein, 2010




1 1 12

*




”bat sign”- 2 rib shadows- Intercostal window- Pleura- Underlying artefact




Emergency chest ultrasound Emergency chest ultrasound = search for artifacts

Dynamic Signs Static Signs

All lung signs arise at the level of the pleural line

For practical purposes, they were given short names using an alphabetic classification,and sorted by relevance.

Lichtenstein D. 1997, Rev Pneumol Clin 53:63–68L’echographie pulmonaire: une methode d’avenir en medecine d’urgence et de reanimation?

*




*PLEURAL EFFUSION CONSOLIDATION

ALVEOLAR-INTERSTITAL SDR PNEUMOTHORAX

NORMAL PATTERN




*Anesthesiology 2004




*

A-Profile B-Profile AB-Profile

A-LINES

present

LUNG SLIDING

abolished

B-LINESA-ProfileB-Profile AB- orC-Profile

PULMONARYEDEMA

PNEUMONIA Venousanalysis

Thrombosis Free veins

PULMONARYEMBOLISM

PNEUMONIA +”lung point”

PNEUMOTHORAX

No”lung point”

Need forother

diagnosticmodalities

Stage III

NO PLAPSPLAPS*

PNEUMONIA COPD/ASTMA*PLAPS= posterior/lateralalveolar and/or pleuralsyndrome

Correct diagnosis in 90.5%of cases (N=260)

LICHTENSTEIN et al




Lanctôt J-F, Valois M, BeaulieuYEGLS:

Echo-guided life supportAn algorithmic approach to undifferentiated shock

ORIGINAL ARTICLE

November 2011

PNEUMOTHORAX ?

TAMPONADE ?

HYPOVOLEMIA ?

POOR LV-FUNCTION ?

RV-STRAIN ?




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