ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance: endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine.

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness Criteria for Stress Echocardiography. A report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine.

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Being ready to treat Ebola virus disease patients.

As the outbreak of Ebola virus disease (EVD) in West Africa continues, clinical preparedness is needed in countries at risk for EVD (e.g., United States) and more fully equipped and supported clinical teams in those countries with epidemic spread of EVD in Africa. Clinical staff must approach the patient with a very deliberate focus on providing effective care while assuring personal safety. To do this, both individual health care providers and health systems must improve EVD care. Although formal guidance toward these goals exists from the World Health Organization, Medecin Sans Frontières, the Centers for Disease Control and Prevention, and other groups, some of the most critical lessons come from personal experience. In this narrative, clinicians deployed by the World Health Organization into a wide range of clinical settings in West Africa distill key, practical considerations for working safely and effectively with patients with EVD.

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine.

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Importance of transesophageal echocardiography in the critically ill and injured patient.

Echocardiography, particularly transesophageal echocardiography (TEE), is a vital diagnostic and monitoring imaging modality for the intensivist. The field of echocardiography spans different venues and pathologies, ranging from surface transthoracic echocardiography and portable hand-held echocardiography, to contrast echocardiography, stress echocardiography, and TEE, among others. Numerous investigations have proven the worth of echocardiography, especially TEE, in the critically ill and injured patient, changing lives with the identification of obvious and subtle cardiothoracic diseases. Because this powerful imaging tool is immediately available and portable, crucial delays in diagnosis are not commonplace; rather than echocardiography, TEE, specifically, should be (and is in some institutions) the standard of care and management in assisting the intensivist in diagnosis of a variety of maladies. The effect of TEE technology is quite formidable, and numerous investigations have borne this out. The therapeutic effect of TEE ranges from 10% to 69%, with the majority of investigations falling into the 60% to 65% range. The diagnostic yield of TEE is far greater, approaching 78%. This article will detail the importance of echocardiography, its efficacy, and its high-yield imaging capability, particularly when compared with other imaging modalities, even transthoracic echocardiography.

Echocardiographic evaluation of hemodynamic parameters.

Hemodynamic assessment is a constant and common task in critically ill and injured patients. Correct interpretation of this data is vital to implement the appropriate intervention, if any. It can be difficult to properly interpret derived and measured data from a pulmonary artery catheter for optimal care of these difficult patients. Catheter use remains controversial because some researchers believe there is no clear benefit to the mortality rate. This conundrum will never be settled without a prospective blinded study. However, echocardiography is a vital and reliable monitoring tool to interrogate pressures, ventricular function, ventricular volumes, ventricular interactions, and diastolic compliance. In some institutions, it is used to construct a pressure/volume curve to measure contractility, which is load-dependent. Echocardiography easily can measure intracardiac pressures accurately but in a static fashion, which is one of its major benefits.

Aortic pathology: aortic trauma, debris, dissection, and aneurysm.

The aorta is a conduit from the left ventricle that delivers pulsatile blood distally in either a compliant or stiffened vessel to organs and tissue beds. Only recently, since the advent of transesophageal echocardiographic imaging, did its presence and associated pathologies become more profound and more prominent for the intensivist. Angiography, the "gold standard" for diagnostic imaging, now seems to be in question since the advent of ultrasound (transesophageal echocardiography), improvements in magnetic resonance imaging, and particularly the advancement to 64-slice computed tomography. It is now a revelation of how revealing these newer imaging tools have expanded our knowledge potential of pathologies that involve the aorta. The latter three imaging modalities are continuing to improve, with established efficacy, particularly in the critically ill and injured patient. This article will enlighten the intensivist and others of their potential and contrast each imaging device in several prominent pathologies common to the critical care physician. The disadvantages of all will be brought forth. Evidence will be presented revealing the dynamic nature of imaging technologies that will continue to affect the outcome of our patients. The most common indications for interrogation of the aorta are in traumatic events in which there might be a catastrophic transection, intimal tear or flap, or subadventitial tear. The identification of hematomas (by these imaging devices) in the mediastinum might be associated with significant physical forces, and this article will show the relevance. The significance of atherosclerotic plaques, ulcers, and debris will also be debated. Finally, imaging of a patient with aortic dissection or aneurysm will be discussed, as its pathology and pathogenic process are well known, and the changing nature or paradigm shift in the imaging of this life-threatening disease will be addressed.

A suggested curriculum in echocardiography for critical care physicians.

Echocardiography is a powerful diagnostic and monitoring tool of cardiac performance, cardiac pathology, and extracardiac intrathoracic abnormalities. Numerous investigations in intensive care have shown its merit, being efficacious and safe. Because many obvious and/or unsuspected conditions can impact the hemodynamic status of critically ill patients, echocardiography is becoming an integral part of an intensivist's diagnostic and monitoring armamentarium. However, significant background information, cognitive, and technical skills are required to properly perform and interpret echocardiography images. Some education and training guidelines for echocardiography have been developed while others remain "in progress." This manuscript suggests a core curriculum and necessary training elements for intensivists. This curriculum does not segregate portable handheld surface echocardiography from the typical platforms of transthoracic echocardiography and transesophageal echocardiography, because hardware and software developments have bridged these technologies.

A correlation of catecholamine and vasoactive Peptide release with hemodynamics in patients undergoing resection of arteriovenous malformations.

INTRODUCTION: Control of blood pressure can be a problem for intracranial procedures. To investigate the relationship between hemodynamic variables and endogenous vasoactive substances, we studied patients undergoing resection of arteriovenous malformations (AVMs). METHODS: This was a nonrandomized, prospective study of six patients who had resection of an intracranial AVM and six patients who had clipping of an intracranial aneurysm (ICA) that had not bled. Operative and postoperative blood pressure was controlled with sodium nitroprusside. Heart rate (HR), mean arterial pressure, pulmonary capillary wedge pressure, and cardiac index (CI) were measured after induction of anesthesia; before, during, and after hypotensive anesthesia; immediately postoperatively; and at 12, 24, and 36 hours postoperatively. Blood samples were drawn simultaneously in the AVM group to measure levels of norepinephrine, epinephrine, renin, aldosterone, vasopressin, angiotensin I, and angiotensin II and correlated with significant hemodynamic changes. RESULTS: HR and CI increased significantly among patients with AVMs compared with patients with ICAs (p<0.001 and p=0.05, respectively). HR was significantly correlated with renin (r=0.60), norepinephrine (r=1.00), and vasopressin (r=0.66). CI was significantly correlated with epinephrine (r=1.00), renin (r=0.77), angiotensin II (r=0.71), and vasopressin (r=0.82). Patients with AVMs had a hyperdynamic state characterized by increases in HR and CI. These increases were accompanied by increased renin, norepinephrine, vasopressin, epinephrine, and angiotensin II serum concentrates. CONCLUSIONS: There were no significant differences in blood pressure changes between patients who had resection for AVM and those who had clipping of ICA, probably due to the use of sodium nitroprusside in the AVM group. Patients with AVMs had a hyperdynamic state with increases in epinephrine, norepinephrine, angiotensin II, plasma renin activity, and vasopressin. Whether this hyperdynamic state is caused by the resection of the AVM or the use of sodium nitroprusside (SNP) cannot be concluded. Blockage of these mediators preoperatively may help control blood pressure without sodium nitroprusside.

Comparison of three remifentanil dose-finding regimens for coronary artery surgery.

OBJECTIVES: To identify the remifentanil dosing regimen providing safe and optimal anesthetic conditions during coronary artery bypass graft surgery and to evaluate postoperative recovery characteristics. DESIGN: Open-label, randomized, parallel group. SETTING: Three centers in the United States. PARTICIPANTS: Seventy-two patients with left ventricular stroke volumes >or=50 mL. INTERVENTIONS: Patients were randomized to remifentanil doses of 1 microg/kg/min (group 1, n = 23); 2 microg/kg/min (group 2, n = 24), or 3 microg/kg/min (group 3, n = 25). Somatic, sympathetic, and hemodynamic responses indicating inadequate anesthesia were treated with bolus doses of remifentanil, 1 to 2 microg/kg, and infusion rate increases, and, if necessary, isoflurane 0.5% to 1.0% was added as a rescue anesthetic. In the intensive care unit, the remifentanil infusion was reset to 1 microg/kg/min, with midazolam administered for supplemental sedation and morphine for analgesia. MEASUREMENTS AND MAIN RESULTS: The durations of anesthesia, surgery, and cardiopulmonary bypass were similar for the 3 study groups. In addition, dose of lorazepam premedication, time to loss of consciousness, preoperative left ventricular ejection fraction, age, weight, and sex were similar for the 3 study groups. Remifentanil alone (infusion and boluses) prevented and controlled all responses to stimulation in 44% of group 3, 37% of group 2 and 9% of group 1 patients intraoperatively. Isoflurane (0.5%-1% inspired) rescue was successful in the remaining patients in each group. Hypotension indicating discontinuation of isoflurane and reductions of remifentanil infusion rates occurred in 64% to 75% of all patients. The optimal range of remifentanil infusion was 2 to 4 microg/kg/min with isoflurane to supplement the opioid. Fifty-one patients (71%) met the criteria for extubation within 6 hours postoperatively; because of surgical practice differences, only 30 patients (59%) were actually extubated. CONCLUSIONS: After lorazepam premedication, remifentanil infusion (2-4 microg/kg/min) supplemented intermittently with low inspired concentrations of isoflurane provided an effective anesthetic regimen for coronary artery bypass graft surgery. Early extubation times were feasible after remifentanil continuous infusions (1-5 microg/kg/min) used as the primary anesthetic component intraoperatively and for analgesia (