Bedside Ultrasonography in the ICU: Part 2

doi:10.1378/chest.128.3.1766

Chest

Volume 128, Issue 3, September 2005, Pages 1766-1781

https://doi.org/10.1378/chest.128.3.1766 Get rights and content

This is the second of a two-part review on the application of bedside ultrasonography in the ICU. In this part, the following procedures will be covered: (1) echocardiography and cardiovascular diagnostics (second part); (2) the use of bedside ultrasound to facilitate central-line placement and to aid in the care of patients with pleural effusions and intra-abdominal fluid collections; (3) the role of hand-carried ultrasound in the ICU; and (4) the performance of bedside ultrasound by the intensivist. The safety and utility of bedside ultrasonography performed by adequately trained intensivists has now been well demonstrated. This technology, as a powerful adjunct to the physical examination, will become an indispensable tool in the management of critically ill patients.

Section snippets

Complications After Cardiac Surgery

Bedside echocardiography has proved to be of particular value in the management of patients with hemodynamic instability in the cardiothoracic ICU.⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹ TTE is often severely limited in this group of patients.⁷, ¹² TEE is thus the modality of choice in this setting, as it provides detailed information that can help determine the cause of refractory hypotension. The most frequent echocardiographic diagnoses encountered in this population of patients are left ventricular (LV) and/or

Infective Endocarditis

Infective endocarditis (IE) is a common presenting diagnosis or complication in ICU patients. IE has been reported to be the second most common indication for performance of echocardiography in the ICU.¹², ¹⁵, ¹⁶ In the critically ill patient, multiple indwelling catheters, parenteral nutrition, severe underlying disease, altered GI mucosal permeability, and prolonged mechanical ventilation increase the likelihood of bacteremia and subsequent endocarditis. Classical clinical findings suggestive

Assessment of the Aorta

In the ICU setting, use of bedside echocardiography for assessment of suspected aortic pathologies provide many advantages over CT or aortography: there is no need for IV contrast, there may be less time delay, there is no need for transportation of the critically ill patient, and cardiac morphology and function can be evaluated at the same time.²⁴ Aortography has for many years been the “gold standard” for the investigation of suspected injuries of the aorta.²⁴ The advent of noninvasive

Assessment for Intracardiac and Intrapulmonary Shunts

In critically ill patients, clinical suspicion for an intracardiac or intrapulmonary shunt will most often be raised in the context of unexplained embolic stroke or refractory hypoxemia. In such cases, the presence of a right-to-left shunt needs to be excluded. Common origins of right-to-left shunt are atrial septal defect (ASD) or patent foramen ovale (PFO) at the cardiac level,¹² and arteriovenous fistula at the pulmonary level.¹² A PFO is present in 25 to 30% of the normal population.¹⁷, ¹⁹

Source of Embolus

In the setting of acute unexplained stroke, echocardiography will often be required to determine if a potential embolic source of cardiac origin is present.³⁶, ³⁷ TEE examination is the modality of choice for this purpose.³⁶, ³⁷ Possible cardiac sources of emboli to the arterial circulation include LA and/or appendicular thrombus, LV thrombus, thoracic atheromatosis, and right-sided clots (RA, RV, vena cava) combined with a right-to-left intracardiac shunt (leading to a “paradoxical embolus”).

Use of Contrast and Harmonic Technology To Enhance Transthoracic Examinations With Poor Image Quality in the Critically Ill Patient

Approximatively 30% of patients will have suboptimal endocardial delineation by fundamental imaging.³⁸ Two developments in ultrasound have improved the quality of endocardial border definition: harmonic imaging and IV contrast echocardiography.³⁹ Dramatic improvements in image quality have been achieved with the development of harmonic imaging. This technology exploits the formation of ultrasound signals that return to the transducer at a multiple of the transmitted (fundamental) frequency,

Impact of Bedside Echocardiography in the Critically Ill Patient

Since its introduction into clinical practice in 1970, the PAC has been the standard hemodynamic monitoring technique for critically ill patients in the ICU, providing the clinician with indexes of cardiovascular function to assist in therapeutic decision making.⁴⁶, ⁴⁷, ⁴⁸ The PAC can be a very useful diagnostic tool in aiding the management of critically ill patients, but it is clear that its inappropriate use and poor interpretation of the data it provides can lead to excessive morbidity and

Central Line Placement

Central venous catheterization is frequently performed in critically ill patients. Placement of a central venous catheter is not without risk and can be associated with adverse events that are both hazardous to patients and expensive to treat.⁵⁶, ⁶⁴, ⁶⁵ Complications have been reported in up to 15 to 20% of cases.⁶⁶, ⁶⁷, ⁶⁸ Complications related to central venous line placement are most often mechanical (arterial puncture, local hematoma, hemothorax, pneumothorax), infectious (catheter

Hand-Carried Ultrasound

The traditional physical examination is often significantly limited in the diagnosis of cardiopulmonary pathology.¹¹⁵, ¹¹⁶, ¹¹⁷ These diagnostic shortcomings are exaggerated in acutely ill ICU patients.¹¹⁸ Hand-carried ultrasounds (HCUs) are a new generation of portable ultrasound machines that are lightweight (6 to 10 lb), battery powered, and much less expensive (< $15,000) than the sophisticated “high-end” machines.¹¹⁷ Despite the fact that their initial introduction into clinical patient

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Reproducibility and accuracy of a pocket-size ultrasound device in assessing liver steatosis
2023, Digestive and Liver Disease
This diagnostic prospective study compared the feasibility and diagnostic accuracy of Pocket-size Ultrasound Devices (PUDs) against standard ultrasound (US) in detecting liver steatosis using the controlled attenuation parameter (CAP) and liver biopsy as reference standards.
Consecutive patients with chronic liver diseases were assessed for the presence of steatosis using PUD and US. A CAP cut-off value >275 dB/m was applied to establish ≥S1. A 26-patient subgroup underwent liver biopsy. PUD reproducibility was evaluated using Cohen's k statistic. Diagnostic accuracy of PUD and US was given as Sensibility (Sn), Specificity (Sp), Positive and Negative Predictive Values (PPV, NPV), positive and negative Likelihood Ratio (LR+, LR-).
81 consecutive patients (69% males) with multiple etiologies were enroled. PUD inter-observer agreement was good (k 0.77, 95%CI 0.62–0.93). PUD and US identified ≥S1 according to CAP values respectively with Sn 0.87, Sp 0.61, PPV 0.49, NPV 0.91, LR+ 2.04, LR- 0.07, AUROC 0.74 and Sn 0.96, Sp 0.54, PPV 0.47, NPV 0.97, LR+ 2.10, LR- 0.07, AUROC 0.75.
PUD shows good reproducibility and diagnostic accuracy in ruling liver steatosis out, representing a useful point-of-care tool to avail of hepatologists interested in excluding NAFLD, but with basic US skills.
Application of Focused Assessment with Sonography for Trauma in the Intensive Care Unit
2022, Clinics in Chest Medicine
Point-of-Care Echocardiography: A Useful Tool for Assessing Complex Arrhythmias in the Pediatric Intensive Care Unit
2021, Journal of Cardiothoracic and Vascular Anesthesia
To demonstrate that the analysis of the atrioventricular, intraventricular, and interventricular asynchrony by point-of-care ultrasound (POCUS) could be an alternative tool for assessing complex arrhythmias in pediatric patients with congenital heart diseases, mainly when an epicardial register or electrophysiology study is not available.
Descriptive, retrospective case series study.
The pediatric intensive care unit of a university-affiliated tertiary hospital in Spain.
The authors included 12 patients with congenital heart disease younger than 18 years admitted to the authors’ pediatric intensive care unit (PICU) from January 2018 to December 2019, with complex arrhythmias after surgery, managed by performing a bedside echocardiography when an electrophysiology test or epicardial auriculogram was unavailable.
None.
The authors included a total of 14 complex arrhythmias in 12 postsurgical patients in whom a comprehensive transthoracic electrocardiogram was not conclusive. The presence of atrioventricular, intraventricular, or interventricular asynchrony was assessed in standard echo views by performing M-mode and Doppler mitral inflow analysis, checking the heart motion. The final POCUS diagnoses were atrial flutter (n = 5), postsurgical atrioventricular block (n = 4), asynchrony induced by pacemaker (n = 2), junctional ectopic tachycardia (n = 1), nodal rhythm plus ventricular extrasystole (n = 1), and supraventricular tachycardia (n = 1). In all patients, regardless of the type of arrhythmia, detecting motion asynchrony was crucial for making the correct diagnosis. Offline cardiologist analysis of the POCUS scans showed full agreement.
POCUS is a useful tool for initial diagnosis and management of complex arrhythmias in the PICU, mainly when epicardial auriculogram or electrophysiology studies are unavailable.
Impact of point of care ultrasound on the number of diagnostic examinations in elderly patients admitted to an internal medicine ward
2020, European Journal of Internal Medicine
A practical approach to critical care ultrasound
2019, Journal of Critical Care
Diagnostic Accuracy of Critical Care Transesophageal Echocardiography vs Cardiology-Led Echocardiography in ICU Patients
2019, Chest
Critical care transesophageal echocardiography (ccTEE) performed by intensivists is increasingly used to investigate cardiorespiratory failure in the ICU. Validation of the accuracy of TEE in the hands of intensivists remains largely unknown. The goal of this study was to characterize the diagnostic accuracy of ccTEE.
This study was a two-center, retrospective comparison between TEE studies performed and interpreted by intensivists and cardiology-led TEE or transthoracic echocardiography (TTE) performed and/or interpreted by cardiologists. The study period was December 2012 to December 2016 for all consecutive ICU patients who received an initial ccTEE and either a cardiology TEE or TTE within 72 h. Using the cardiology-conducted examination as the gold standard, we reported sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of ccTEE.
Comparisons between ccTEE and cardiology TEE/TTE performed yielded 56 patients (five ccTEE vs cardiology TEE and 51 ccTEE vs cardiology TTE). The comparison between ccTEE and cardiology TEE showed 100% sensitivity, specificity, PPV, NPV, and accuracy for the primary diagnosis and other major findings. For the combined ccTEE and cardiology TEE/TTE comparison, there was a high sensitivity/specificity/PPV/NPV/accuracy for the primary diagnosis (90%-100% range), as well as other major diagnoses (88%-100% range).
This study showed that ccTEE has a high sensitivity, specificity, PPV, NPV, and accuracy compared with the gold standard cardiology TEE or TTEs in critically ill patients, when performed by advanced echocardiogram-trained/experienced intensivists.

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Chest

Critical Care ReviewsBedside Ultrasonography in the ICU: Part 2

Section snippets

Complications After Cardiac Surgery

Infective Endocarditis

Assessment of the Aorta

Assessment for Intracardiac and Intrapulmonary Shunts

Source of Embolus

Use of Contrast and Harmonic Technology To Enhance Transthoracic Examinations With Poor Image Quality in the Critically Ill Patient

Impact of Bedside Echocardiography in the Critically Ill Patient

Central Line Placement

Hand-Carried Ultrasound

Mayo Clin Proc

Mayo Clin Proc

Crit Care Clin

Chest

Am Heart J

J Cardiovasc Thorac Surg

Cardiol Clin

J Am Coll Cardiol

J Am Coll Cardiol

Chest

J Am Coll Cardiol

Lancet

Am Heart J

Progr Cardiovasc Dis

Am Heart J

Am J Cardiol

J Am Soc Echocardiogr

Am J Cardiol

Crit Care Clin

Am Heart J

J Am Coll Cardiol

Chest

Chest

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

Chest

Am J Cardiol

Chest

Am Heart J

J Am Coll Cardiol

Br J Anaesth

Chest

Chest

Chest

Chest

Chest

Surg Clin North Am

Arch Phys Med Rehab

Med Clin North Am

The role of state-of-the-art echocardiography in the assessment of myocardial injury during and following cardiac surgery

Ann Thorac Surg

Transesophageal echocardiography in critically ill patients

Crit Care Med

Clinical and echocardiographic diagnoses disagree in patients with unexplained hemodynamic instability after cardiac surgery

Can J Anaesth

Prediction of postoperative cardiac surgical morbidity and organ failure within 4 hours of intensive care unit admission using esophageal Doppler ultrasonography

Crit Care Med

Indications and impact of postoperative transesophageal echocardiography in cardiac surgical patients

Crit Care Med

The hemodynamically unstable patient in the intensive care unit: hemodynamic vs. transesophageal echocardiographic monitoring

Crit Care Med

Transesophageal echocardiography in the intensive care unit: impact on diagnosis and decision-making

Clin Cardiol

Transesophageal echocardiography in the critical care unit

Cleve Clin J Med

Critical Care Reviews
Bedside Ultrasonography in the ICU: Part 2