The use of echocardiography in the critically ill; the role of FADE (Fast Assessment Diagnostic Echocardiography) training.

Echocardiography (echo) is a powerful technique that permits direct visualization and assessment of all the cardiac structures and assessment of the patients' haemodynamic status at the bedside. Echo allows detection of valvular disease, evaluation of ventricular function and the pericardium, detection of intracardiac/intrapulmonary shunts, and can be used to calculate flows and relative pressures between the cardiac chambers. This rapid point-of-care haemodynamic evaluation provides information to guide therapeutic interventions, including volume resuscitation, instigation of vasoactive therapy and/or referral for specialist cardiac/surgical intervention. Although there is abundant evidence in the cardiology literature regarding the use of echo, data in the critical care arena is less well defined, but emerging. The use of echo by intensive care doctors is likely to become routine, and therefore training for intensivists in this technique needs to be developed and supported. The Portuguese Working Group on Echocardiography has developed a skill-based program, FADE (Focused Assessment Diagnostic Echocardiography) in order to train clinicians in the use of bedside ultrasound as a diagnostic and monitoring tool for the critically ill.

Routine transthoracic echocardiography in a general Intensive Care Unit: an 18 month survey in 704 patients.

The authors analyzed 704 transthoracic echocardiographic (TTE) examinations, performed routinely to all admitted patients to a general 16-bed Intensive Care Unit (ICU) during an 18-month period. Data acquisition and prevalence of abnormalities of cardiac structures and function were assessed, as well as the new, previously unknown severe diagnoses. A TTE was performed within the first 24 h of admission on 704 consecutive patients, with a mean age of 61.5+/-17.5 years, ICU stay of 10.6+/-17.1 days, APACHE II 22.6+/-8.9, and SAPS II 52.7+/-20.4. In four patients, TTE could not be performed. Left ventricular (LV) dimensions were quantified in 689 (97.8%) patients, and LV function in 670 (95.2%) patients. Cardiac output (CO) was determined in 610 (86.7%), and mitral E/A in 399 (85.9% of patients in sinus rhythm). Echocardiographic abnormalities were detected in 234 (33%) patients, the most common being left atrial (LA) enlargement (n=163), and LV dysfunction (n=132). Patients with these alterations were older (66+/-16.5 vs 58.1+/-17.4, p<0.001), presented a higher APACHE II score (24.4+/-8.7 vs 21.1+/-8.9, p<0.001), and had a higher mortality rate (40.1% vs 25.4%, p<0.001). Severe, previously unknown echocardiographic diagnoses were detected in 53 (7.5%) patients; the most frequent condition was severe LV dysfunction. Through a multivariate logistic regression analysis, it was determined that mortality was affected by tricuspid regurgitation (p=0.016, CI 1.007-1.016) and ICU stay (p<0.001, CI 1-1.019). We conclude that TTE can detect most cardiac structures in a general ICU. One-third of the patients studied presented cardiac structural or functional alterations and 7.5% severe previously unknown diagnoses.

Cardiac tamponade secondary to methicillin-resistant Staphylococcus aureus pericarditis.

Since the advent of antibiotics, bacterial pericarditis has become relatively rare. Cardiac tamponade is a potentially lethal complication, especially when caused by methicillin-resistant Staphylococcus aureus (MRSA). In the intensive care setting other predisposing factors for purulent pericarditis, besides immunosuppression, are the high incidence of nasal and skin colonization and invasive techniques such as indwelling catheters. We present two case reports of cardiac tamponade in young patients, with underlying immunosuppression of different etiologies (HIV infection and liver transplantation). In both, clinical evolution was complicated by severe sepsis, with MRSA being isolated in various biological products, followed by bacterial pericarditis and tamponade. The authors highlight the need for a high degree of suspicion for the diagnosis of bacterial pericarditis in immunosuppressed patients, an ever-growing population, as well as the importance of echocardiographic monitoring during clinical evolution.

Prevalence and clinical characterisation of patients with severe partial respiratory failure admitted to an intensive care unit.

OBJECTIVE: The authors analysed patients with severe partial respiratory failure (SPRF) admitted to a general Intensive Care Unit (ICU). The prevalence and clinical characteristics of these patients were evaluated. This work aims to study the rate of and to clinically characterise the patient population admitted to an Intensive Care Unit with acute severe partial respiratory failure. MATERIAL AND METHODS: In 16-bed ICU of a central Hospital in Lisbon, patients admitted in the year 2004 were analysed. Patients with SPRF were recruited form patients with an ICU stay> 24 hours. They were selected according to PaO2 and FiO2 and clinically characterized. RESULTS: During the study period 472 patients were admitted, and 378 presented an ICU stay> 24 hours and were enrolled. From those, 142 (37.6%) met criteria for SPRF. Of these, 45 (31.7%) a pulmonary aetiology of SPRF was identified. Patients with SRPF were older, had longer ICU stay, and presented higher severity indexes and mortality. The prevalence of adult respiratory distress syndrome was possible to evaluate in the deceased patients with SPRF (n=52). In these we could find 12 (23%) patients that met criteria for that entity. By multivariate analysis the mortality of patients with SRPF correlated with older age and the presence of circulatory failure (p<0.001). CONCLUSIONS: SPRF is a situation highly prevalent in the ICU studied. To better understand the prevalence of this entity, properly designed studies are needed in order to establish its epidemiology and clinical characteristics.

[Pneumocystis and cytomegalovirus pneumonia in HIV patients - two clinical cases]. / Pneumonia por Pneumocystis e citomegalovírus no doente VIH - A propósito de dois casos clínicos.

Cytomegalovirus is capable of causing disease in immunocompromised patients. In people infected by the Human Immunodeficiency Virus (HIV) it becomes an important agent when there is advanced immunosupression. Its role as a pulmonary pathogen in these patients has been questioned. In the case of pneumocystosis the presence of Cytomegalovirus doesn't seem to worsen prognosis, except in cases where corticosteroids are used. Authors present two cases of patients with HIV infection and advanced immunosupression who were admitted in the intensive care unit for respiratory failure. In both Pneumocystis jirovecii was isolated from.

[Cardiac influence on mechanical ventilation time and mortality in exacerbated chronic respiratory failure patients. The role of echocardiographic parameters].

OBJECTIVE: To study the influence of cardiac status on the length of mechanical ventilation, outcome and disease severity in patients admitted to an Intensive Care Unit (ICU) with exacerbation of chronic respiratory failure. DESIGN AND SETTING: A 30-month prospective study in a 14 bed ICU PATIENTS AND METHODS: Fifty nine patients were enrolled, with a mean age 74.7 +/- 9.7 years, mean length of ventilator support 10.8 +/- 12.6 days, and mean APACHE II score 23 +/- 8.3. Within the first 24 hours of admittance, cardiac chamber dimensions, inferior vena cava (IVC), and mitral transvalvular Doppler were evaluated using transthoracic echocardiography; the cardiac rhythm was recorded (presence of sinus rhythm or atrial fibrillation). Blood gases were evaluated at discharge. RESULTS: Greater length of ventilation was observed in patients presenting atrial fibrillation (p=0.027), particularly when a dilated IVC was also present (>20mm, p=0.004). A high level of serum bicarbonate (>35 mEq/l), was also related with longer ventilation (p=0. 04). Twelve patients died. Mortality was related to the presence of a dilated right ventricle (p=0. 03) and a ratio between right and left ventricle> 0. 6 (p=0.04). CONCLUSION: Patients submitted to mechanical ventilation due to exacerbation of chronic respiratory failure which present atrial fibrillation require a longer ventilation period, particularly if a dilated IVC is also present. Patients with dilated right cardiac chambers are at an increased risk of a fatal outcome.

[Transthoracic echocardiography for evaluation of hypotensive critically ill patient]. / A ecocardiografia transtorácica na avaliação da hipotensão em cuidados intensivos polivalentes.

OBJECTIVES AND DESIGN: a prospective study to determine the value of transthoracic echocardiography (TTE) in assessing hypotensive patients in a medical/surgical Intensive care Unit (ICU). SETTING: a 16-bed medical/surgical ICU. MATERIAL AND METHODS: patients with hypotension were studied (systolic arterial pressure < 90 mmHg or mean arterial pressure < 60 mmHg, non responsive to fluid therapy in a 30-minute period). TTE was aimed to: exclude severe cardiac dysfunction(abnormalities requiring immediate therapeutic decision); to evaluate other non severe cardiac alterations; to determine cardiac index (CI) and analyse inferior vena cava (IVC). RESULTS: Two hundred eight patients were studied, and 198 enrolled (4.5% of impossible examinations), with a mean age 63.4 +/- 16.2 years, 129 male, APACHE II score 30.1 +/- 9.9, SAPS II 68.8 +/- 20.5, SOFA 11.6 +/- 3.8, MODS 10.9 +/- 3.9. Mortality was 51% (n=101) and 168 (82.2%) patients were under mechanical ventilation. Forty four patients (44.4%) presented cardiac abnormalities, 28 of whom (14%) severe cardiac diseases. Of these, 18 (9%) presented unsuspected situations (aortic stenosis, 3; endocarditis, 4, dilated miocardiopathy, 9, cardiac tamponade, 2). Patients with cardiac abnormalities were older and presented higher severity scores and mortality. Most patients (158, 79.7%) presented a normal/high IC, all with low peripheral vascular resistance. Through logistic regression analysis, a statistically significant between IVC index and ICU stay (p=0.05); IC and IVC index correlated with overall mortality (p=0,008 and 0,041 respectively). CONCLUSIONS: Patients with hypotension in a medical/surgical ICU presented a high rate of cardiac abnormalities (44.4%, n=88), including 26 patients with severe diseases, requiring immediate therapeutic decisions. IC and IVC analysis may be useful to determine hemodynamic profile and several TTE parameters may have prognostic value.

[Hybrid or continuous renal replacement techniques for unstable haemodynamic patients in the intensive care unit]. / Técnicas dialíticas híbridas ou hemodiafiltração para doentes hemodinâmicamente instáveis em cuidados intensivos.

OBJECTIVE: Comparative study to evaluate the impact of a hybrid renal replacement technique (HRRT) vs a continuous renal replacement technique (haemodiafiltration) on hemodynamic tolerance, azotemic control, and mortality in critical care patients with acute renal failure. SETTING: a 14-bed Intensive Care Unit (ICU). MATERIAL AND METHODS: Two groups of patients were retrospectively compared: patients submitted to continuous renal replacement techniques (CRRT) in 2003 (n = 26) and patients who underwent HRRT in 2004 (n = 27). Both groups had similar severity scores and underlying diseases, and were haemodynamically unstable. Urea and creatinine reduction ratio (URR and CRR) in both groups were evaluated. RESULTS: Patients treated with HRRT presented a lower mortality (62% vs 84%), less heparin use, and a higher URR and CRR. Univariate logistic regression showed that an increase in APACHE II was related to an increase in mortality (CI 95%, 1.03-1.26). Odds for mortality for CRRT group were about 3 times higher (CI 95%, 0.86-12.11), but not statistically significant (p = 0.074). CONCLUSION: HRRT is a valid alternative to CRRT in haemodynamically unstable critically ill patients.

Haemodynamic parameters obtained by transthoracic echocardiography and Swan-Ganz catheter: a comparative study in liver transplant patients.

OBJECTIVE: To compare the haemodynamic measurements of cardiac output (CO), central venous pressure (CVP), pulmonary capillary wedge pressure (Pw) and pulmonary artery systolic pressure (PASP), obtained by Swan-Ganz catheter and transthoracic echocardiography. MATERIAL AND METHODS: Prospective study in a Medical/Surgical Intensive Care Unit (ICU). A total of 41 post liver transplant patients were enrolled. CO, CVP, Pw and PASP, were simultaneously determined by two independent observers, utilizing a Swan-Ganz catheter and transthoracic echocardiography, using equations described in the literature. A linear correlation and a Bland-Altman analysis were performed. RESULTS: A good correlation between invasive and non- invasive measurements for CO (r=0.97) and CVP (r=0.88) was found, but determinations of Pw (r=0.41) and PASP (r=0.18) did not correlate well. Bias and 95% confidence interval for CO were negligible namely when a CO<6 l/min was considered. Pulsed-wave Doppler-echocardiography underestimates the CO when compared with thermodilution, but the 2 techniques agree on average and can be used interchangeably. CONCLUSIONS: The non-invasive determination of CO in critical care post liver transplant patients correlates well with the invasive determinations. Transthoracic echocardiography was not appropriate for calculating filling parameters studied. Although the data was obtained in post liver transplant patients, they could be useful in defining the role of echocardiography in the ICU.

[Lymphopenia in patients submitted to assisted ventilation due to aggravated chronic respiratory failure: a prospective study]. / Linfopénia em doentes submetidos a ventilação mecânica por exacerbação de insuficiência respiratória crónica: estudo prospectivo.

OBJECTIVES: Evaluate and characterize lymphopenia in patients admitted to the Intensive Care Unit (ICU) for mechanical ventilation due to aggravated chronic respiratory failure and its probable relation to severity. MATERIAL AND METHODS: Prospective study over a period of 6 months with another 6 months follow-up after ICU discharge. The study included 24 patients, 22 males, with mean APACHE II of 19,7, three of whom with capacity for outpatient follow-up. Lymphocyte subpopulations were determined on admission and every 7 days after mechanical ventilation. Patients with evidence of infection or previous immunossupression, with the exception of steroids, were excluded from the study. RESULTS: Lymphopenia was found in 79,2% of patients with depletion of all lymphocyte series, although with greater expression for B lymphocytes CD19+. This depletion showed no relation with serum steroid levels, and although related to greater clinical severity, no correlation was found with mortality. Lymphocyte values recovered progressively during admission. CONCLUSIONS: Lymphopenia is frequent among ventilated patients with chronic respiratory exacerbation. It's a non-selective depletion, more evident with CD19+ B lymphocytes. These patients present higher severity scores but no difference in mortality. Outpatient follow-up was difficult and inconclusive.

Case report: purple urine bag syndrome.

Purple urine bag syndrome (PUBS) was first reported in 1978. PUBS is rare, occurs predominantly in constipated women, chronically catheterized and associated with some bacterial urinary infections that produce sulphatase/phosphatase. The etiology is due to indigo (blue) and indirubin (red) or to their mixture that becomes purple. A chain reaction begins in the gastrointestinal tract with tryptophan as described in the article.

Cardiac Doppler variation with volume status changes in general intensive care.

The authors studied the effect of volume status modification on cardiac Doppler features, with negative fluid balance and corresponding central venous pressure change. This was carried out in 64 patients admitted to the Intensive Care Unit, 24 of whom were under mechanical ventilation. With volume status change, the mitral E/A ratio showed a tendency to decrease, mitral E wave deceleration time decreased, isovolumic relaxation time increased, and the expiratory diameter of the inferior vena cava reduced and its inspiratory collapse increased. No significant correlation was observed between the parameters studied and volume changes, or between central venous pressure and fluid balance. Volume changes in critical care patients modify certain features of Doppler echocardiography, but the magnitude of such variations is unpredictable.

Pulmonary artery catheter--what role in the 21st century?

The pulmonary artery catheter is a diagnostic tool used routinely in cardiological and general intensive care. Since its implementation in the 1970s, serious doubts have been raised concerning its use and efficacy. These problems are a legacy of the 20th century, and may not be solved in this century, but they cannot be ignored. The authors present an overview of this subject, recording in chronological order the principal events and publications concerning the pulmonary artery catheter, highlighting some controversies, most of them unresolved.

The influence of cardiac diastole on weaning from mechanical ventilation.

Hemodynamic changes occur during weaning from mechanical ventilation, especially after disconnection from positive pressure ventilation. Their importance has been insufficiently studied, although some refer to their role in weaning. The authors studied the hemodynamic implications after ventilator disconnection, using echocardiography. They found isovolumetric relaxation time to be a good predictor of successful weaning, proving the importance of the diastole changes with the hemodynamic adaptation in the transition to negative pressure ventilation.

Non-invasive evaluation of central venous pressure by echocardiography.

INTRODUCTION: Central venous pressure (CVP) is an important hemodynamic parameter, reflecting the patient's volume status. Although some studies of non-invasive evaluation of CVP by echocardiography exist, an exact quantitative method has not been described. OBJECTIVES: Analyzing several echocardiographic variables, the authors present an equation to calculate CVP with good statistical correlation with CVP measured invasively. MATERIAL AND METHODS: The study included 45 patients, 32 undergoing mechanical ventilation, 32 in sinus rhythm and 13 with atrial fibrillation. Patients underwent simultaneous CVP measurement and transthoracic Doppler echocardiography. Statistical analysis was performed using bivariate correlation and analysis of variance. RESULTS: Several echocardiographic parameters measured showed a good correlation with the measured CVP. Standardized coefficients were applied to them and an equation to calculate CVP was obtained (tricuspid E decelaration) x 0.11 + (RU/RA gradient) x 0.16 - (IVC variation). CONCLUSION: This new method seems reliable to evaluate non-invasively a hemodynamic parameter that until now has only been measured approximately by this approach.