The Evolving Role of Echocardiography in Sepsis

1. The Evolving Role of
Echocardiography in Sepsis
Dr. Hatem A. Soliman, MSc, MRCP (UK)
Specialist Intensivist
Mafraq Hospital, Abu Dhabi
EACVI Club 35 Ambassador to the UAE

2. “SAY: MY LORD, INCREASE ME
IN KNOWLEDGE”
QUR’AN 20:14
“ ‫لما‬ِ‫ع‬ ِ‫دني‬ِ‫ز‬ ِ‫ب‬َ‫ر‬ ‫ل‬ُ‫ق‬َ‫”و‬
‫العظيم‬‫هللا‬ ‫صدق‬

3. Disclosure
Nothing to disclose

4. Why this lecture ?

5. SSC Response (April 2015)

8. Why Echo ?
• US has become an invaluable tool in the
management of critically ill patients
• Sepsis and Septic Shock (SS) represent complex
situations where early hemodynamic assessment
and support are among the keys to therapeutic
success.
• Sepsis and (SS) are common causes of
cardiovascular failure in ICU and are the most
frequent causes of mortality.

9. Why Echo ?
The Heart; the main target of the Echo
examination, frequently represents itself the
core of the septic process, being either
‘‘a victim’’ (when sepsis-related myocardial
dysfunction develops) or
“a source” (in the context of endocarditis).

10. What’s the Evidence !
• TTE and TEE add new relevant information that
leads to changes in therapy in more than 50% of cases
[1,2,3], the majority of which concern volume
status and inotropy [3];
• Echo seems to be more accurate than the standardized
strategy proposed by the SSC guidelines in the detection
of the dominant features of the failing circulation
[4].

11. Cardiac dysfunction in Sepsis
• Absolute or relative reduction in central blood
volume
• Peripheral vasodilatation.
• Myocardial failure.

12. What is Ultrasound ?
• High frequency sound (pressure) waves.
• > 20.000 (2 kHz): Upper limit of human ears.
• 2-10 mHz: Medical diagnostics range.
• US waves are created by a vibrating crystal
within a ceramic probe.
• Waves travel through tissue and are partly
reflected at each tissue interface.

13. Why Ultrasound ??
• Safe (no radiation)
• Portable (bedside)
• Immediate bedside availability.
• Repeatability.
• Detailed (Focused, limited exam in ICU)
• Easy to learn and perform
• Cost saving
• Improves outcome.

14. Disadvantages of US ?
• Training curve
• Subjective (operator-dependent)
• Poor image quality.
• Reliance on technology.
• Cost
• Maintenance.

15. Modes
• B “Brightness” Mode:
Traditional real time cross sectional scanning mode

16. • M (Motion) Mode:
One dimensional display of motion
Modes

17. Probes

18. Probes

19. Probes

20. Echogenicity
• The more US waves reflected back, the brighter the image.
• Hyper-echoic (bright echo):
– Air
– Diaphragm
– Periostium
• Iso-echoic:
– Liver
– Kidney
– Muscle
• Hypo-echoic (dark echo):
– Fluid
– Blood
– Fat.

21. Enemies of Ultrasound
• Air (MV)
• Bone
• Foreign body
• Calcium
• Any interposed structure
• Poor positioning.
• Lack of patient co-operation
• Surgical wounds and dressings, tapes, tubing,
surgical, emphysema, obesity, and COPD

22. Indications of US
• Vascular access.
• Pleural effusion
• Intra-abdominal fluid collection
• Urinary Bladder Scan
• FAST
• Echocardiography (huge range of indications)

23. Indications of Echo
• Hemodynamic instability
– Ventricular failure
– Hypovolemia
– Pulmonary embolism
– Acute valvular dysfunction
– Cardiac tamponade
– Complications after cardiothoracic surgery
• Infective endocarditis
• Aortic dissection and rupture
• Unexplained hypoxemia
• Source of embolus

25. • Identify existing cardiac dysfunction.
• Volume status (IVC and Echo)
• Cardiac Function assessment
• Identify sepsis-related cardiomyopathy (Early
avoiding extra fluids)
The role of Echo in Sepsis

26. The role of Echo in Sepsis
• Sepsis is a hyperdynamic state !!
• Exclude cardiac causes of sepsis.
• Guiding hemodynamic management.
• DD of shock
• Comprehensive hemodynamic monitoring
(repeat echo)

27. Echo at early Septic Shock
• Small LV
• Small RV
• LV and RV hyperkinesia
• Small IVC
• IVC respiratory collapse (spontaneous ventilation)
• None of the above (but rather a variable degree of
LV or RV
• dysfunction) in the setting of relevant pre-existing
cardiac disease

29. Hyperdynamic LVF for predicting sepsis
• Sensitivity: 33%
• Specificity: 94%

31. Hemodynamic assessment by Echo
• Cardiac output ( LVOT VTI)
• Volume status, volume responsiveness
• LV systolic function
• RV systolic function
• Systemic arterial resistances (indirect, exclusion
criteria)
• LV filling pressures

32. Cardiac Output assessment by Echo
LV outflow tract (LVOT) and aortic valve as the
conduit is probably the most reliable and most
commonly used, with an excellent agreement
with Thermo-dilution in most situations.

33. Anatomy of IVC
• The IVC returns blood from the
body to the right atrium
• Formed by the convergence
of the illiac veins
• Retroperitoneal
• Right of the aorta
• Normal size 1.5-2.5 cm
• During expiration,
• In a spontaneously breathing patient,
• Just distal the hepatic vein
• Varies with respiration

34. Respiratory Variations

35. Respiratory Variations

36. Respiratory Variations

37. Respiratory Variations

38. IVC vs. CVP Guidelines

39. IVC vs. CVP Guidelines

41. M-mode Volume depletion

42. M-mode Volume Overload

45. Dilated IVC
• Volume overload.
• Obstructive Shock:
• Cardiac tamponade
• Tension Pneumothorax.
• Massive PE.
IVC Pearls

46. Dilated IVC
• Mitral regurgitation
• Aortic stenosis
• Status Asthmaticus
• Right Heart Failure.
IVC Pearls

47. Mechanical Ventilation
Causes reversal of IVC changes with respiration
“Maximum diameter with inspiration, minimum diameter with
expiration”
IVC Pearls

48. (False) Collapse of IVC
• Diaphragmatic breathing (Kimura 2011) “Important in the
ICU”
• Raised intra-abdominal pressure (in animal studies: Takata
1990)
• Even pressure from the probe! (anecdotally)
IVC Pearls

49. Resources

56. Mobile Apps

57. EGLS

59. SonoAccess

62. Philips US Education

63. EACVI Club 35

65. Who is eligible?
• Everyone who is interested in cardiovascular
imaging. The cut-off age for
• participation is currently 35 years of age but
from January 2016 eligibility criteria will
• be altered. So stay tuned!

66. • Doctors (cardiologists, intensivists, anaesthetists,
cardiothoracic surgeons, internal medicine
physicians)
• Medical students
• Technicians/sonographers / allied health
professionals (incl. nurses)
Who is eligible?

67. Benefits
• Become a full member of the (EACVI), leading
European Cardiovascular Imaging network.
• Get involved in Several Echo workshops, endorsed by
the EACVI.
• Register for free to all EACVI webinars and their
recordings if you missed the live sessions
• Apply for EACVI Training and Research Grants
• Participate to projects / registries

69. www.escardio.org ( EACVI Club 35)
www.Lifeinthefastlane.com
www.sonosite.com
www.criticalecho.com
www.intensivecarenetwork.com/icusonography
www.emcrit.org
www.sinaiem.us
www.sonospot.com
www.emergencyultrasoundteaching.com
www.thesonocave.com
www.ultrasoundcriticalcare.com
Useful Links

70. • We call for a mandatory training of all
intensivists and ED physicians on US and Echo
basics.
• Learning focused, limited bedside Echo is a life
saver and a game changer tool.
• Hyper-dynamic LV doesn’t mean normal global
function.
• It is mostly accompanied by small collapsed
chambers and IVC.
Take-Home Message

71. • Hyperdynamic LV also is highly specific for
sepsis (94%).
• Bedside Echo currently replaces mandatory
CVP measurement.
• Dynamic frequent re-assessment is the key to
management with Echo.
Take-Home Message

72. Not the Echo result!
Remember
Treat the Patient

73. “The good physician treats the
disease; the great physician
treats the patient who has the
disease”
Quote William Osler

74. “ Patch Adams”

75. References
1. Manasia AR, Nagaraj HM, Kodali RB, Croft LB, Oropello JM, Kohli-Seth R, Leibowitz AB, DelGiudice R, Hufanda JF,
Benjamin E, Goldman ME (2005) Feasibility and potential clinical utility of goal-directed transthoracic
echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically
2. Hu¨ttemann E, Schlenz C, Kara F (2004) The use and safety of TEE in the general ICU—a minireview. Acta
Aanaesthesiol Scand 48:827–836
3. Orme RM, Oram MP, McKinstry CE (2009) Impact of echocardiography on patient management in the intensive care
unit: an audit of district general hospital practice. Br J Anaesth 102:340–344
4. Bouferrachea K, Caille V, Chimot L, Castro S, Charron C, Page B, Vieillard-Baron A (2010) Monitorage
he´modynamique dans le sepsis: confrontation des recommandations de la Surviving Sepsis Campaign a`
l’e´chocardiographie. Re´animation 19S:S32–S33 (Abst)
5. Cloreavy FB, Donovan K, Lee KY, et al. Transesophageal echocardiography in critically ill patients. Crit Care Med 2002;
30:989–996
6. Benjamin E, Griffin K, Leibowitz AB, et al. Goal-directed transesophageal echocardiography performed by intensivists
to assess left ventricular function: comparison with pulmonary artery catheterization. J Cardiothorac Vasc Anesth
1998; 12:10–15
7. Spevack DM, Spevack DM, Tunick PA, et al. Hand carried echocardiography in the critical care setting.
Echocardiography 2003; 20:455–461

76. “AND WHOEVER SAVES A LIFE, IT
IS CONSIDERED AS IF
HE SAVED AN ENTIRE WORLD”
QUR’AN 5:32
“ َ‫ي‬ْ‫ح‬َ‫أ‬‫ا‬َ‫م‬َّ‫ن‬َ‫أ‬َ‫ك‬َ‫ف‬ ‫ا‬َ‫اه‬َ‫ي‬ْ‫ح‬َ‫أ‬ ْ‫ن‬َ‫م‬َ‫و‬‫ا‬‫يع‬ِ‫م‬ََ ََ‫ا‬ََّّ‫ال‬‫ا‬ ”
‫العظيم‬‫هللا‬ ‫صدق‬

77. Thank
Youhatem.soliman@gmail.com
0508669484