Advertisement

A bedside clinical and ultrasound-based approach to hemodynamic instability - Part II: bedside ultrasound in hemodynamic shock: Continuing Professional Development

  • Annette Vegas
  • André Denault
  • Colin Royse
Continuing Professional Development

Abstract

Shock is defined as a situation where oxygen transport and delivery is inadequate to meet oxygen demand. The patient in shock is evaluated through medical history, physical examination, and careful observation of the hemodynamic and respiratory monitors. The patient is initially managed with basic resuscitation measures, however bedside ultrasound should be performed if hemodynamic instability persists. We propose to use ultrasound of the inferior vena cava (IVC), and the concept of venous return, as the initial step in order to identify the mechanism of shock. Doppler examination of the hepatic venous flow can also be added. Further ultrasound examination of the patient’s heart, thorax, and abdomen can then be performed in order to determine the etiology of shock. In patients with reduced mean systemic venous pressure, an examination of the patient’s thoracic and abdominal cavities to detect free fluid, pneumonia, or empyema can be considered. In patients with increased right atrial pressure, transthoracic echocardiography will allow identification of left or right ventricular dysfunction. Finally, in the presence of increased resistance to venous return, thoracic examination for pneumothorax or cardiac tamponade and abdominal examination for signs of abdominal compartment syndrome or IVC occlusion can be considered. Subsequent treatment can then be tailored to the etiology of shock. Elements of bedside ultrasound examination are currently taught in many anesthesia training programs.

Purpose

To develop an approach to the patient in shock that incorporates bedside ultrasound examination.

Keywords

Right Ventricular Inferior Vena Cava Continue Professional Development Right Ventricular Outflow Tract Right Ventricular Failure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Approches cliniques et échographiques au chevet du patient pour la gestion de l’instabilité hémodynamique - 2e partie: l’échographie au chevet en cas de choc hémodynamique

Résumé

On définit le choc comme une situation dans laquelle le transport d’oxygène est incapable de répondre à la demande en oxygène. On évalue le patient en état de choc en fonction de ses antécédents médicaux, de l’examen physique, ainsi que de l’observation minutieuse des moniteurs hémodynamiques et respiratoires. Le patient est d’abord pris en charge à l’aide de mesures de réanimation de base; toutefois, si l’instabilité hémodynamique persiste, il convient de réaliser une échographie au chevet. Nous proposons d’utiliser une échographie de la veine cave inférieure (VCI) dans le cadre du concept du retour veineux, comme première étape dans l’identification du mécanisme du choc. L’examen Doppler des veines hépatiques peut également être ajouté. Un examen échographique plus approfondi du cœur, du thorax et de l’abdomen du patient peut être réalisé par la suite afin de déterminer l’étiologie du choc. Chez les patients dont la pression veineuse systémique est réduite, on peut envisager un examen des cavités thoracique et abdominale afin de détecter du liquide libre, une pneumonie ou un empyème. Chez les patients dont la pression auriculaire droite est accrue, une échocardiographie transthoracique permettra d’identifier le mécanisme du dysfonctionnement ventriculaire gauche ou droit. Enfin, si le retour veineux rencontre une résistance accrue, on peut envisager de réaliser un examen thoracique afin d’exclure la présence de pneumothorax ou de tamponnade cardiaque et un examen abdominal pour détecter les signes d’un syndrome du compartiment abdominal ou d’une occlusion de la VCI. Le traitement subséquent peut alors être personnalisé en fonction de l’étiologie du choc. Des éléments de l’examen échographique au chevet sont actuellement enseignés dans de nombreux programmes de formation en anesthésiologie.

Objectif

Mettre au point une approche du patient en état de choc qui incorpore l’examen échographique au chevet.

Notes

Acknowledgements

The authors sincerely thank Denis Babin and Antoinette Paolitto for their assistance in bringing this manuscript to fruition.

Funding sources

Montreal Heart Institute Foundation.

Conflicts of interest

None declared.

Sources de financement

Fondation de l’Institut de cardiologie de Montréal.

Conflit d’intérêt

Aucun.

Supplementary material

12630_2014_231_MOESM1_ESM.wmv (7.2 mb)
Supplementary material 1 (WMV 7325 kb)
12630_2014_231_MOESM2_ESM.wmv (6.6 mb)
Supplementary material 2 (WMV 6726 kb)
12630_2014_231_MOESM3_ESM.wmv (6.2 mb)
Supplementary material 3 (WMV 6306 kb)
12630_2014_231_MOESM4_ESM.wmv (451 kb)
Supplementary material 4 (WMV 450 kb)

Supplementary material 5 (WMV 8377 kb)

Supplementary material 6 (WMV 816 kb)

12630_2014_231_MOESM7_ESM.wmv (10.5 mb)
Supplementary material 7 (WMV 10763 kb)

Supplementary material 8 (WMV 2803 kb)

12630_2014_231_MOESM9_ESM.wmv (12.1 mb)
Supplementary material 9 (WMV 12422 kb)
12630_2014_231_MOESM10_ESM.wmv (460 kb)
Supplementary material 10 (WMV 459 kb)

Supplementary material 11 (WMV 953 kb)

Supplementary material 12 (WMV 3316 kb)

Supplementary material 13 (WMV 1872 kb)

12630_2014_231_MOESM14_ESM.wmv (538 kb)
Supplementary material 14 (WMV 538 kb)

Supplementary material 15 (WMV 1044 kb)

Supplementary material 16 (WMV 1094 kb)

12630_2014_231_MOESM17_ESM.wmv (54 kb)
Supplementary material 17 (WMV 53 kb)

Supplementary material 18 (WMV 625 kb)

Supplementary material 19 (WMV 928 kb)

12630_2014_231_MOESM20_ESM.wmv (532 kb)
Supplementary material 20 (WMV 531 kb)

References

Note References 35 to 37 are cited in the Clinical Case Question and Answers section of the CPD module that is available to CJA subscribers at http://www.cas.ca/Members/CPD-Online.

  1. 1.
    Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2013; 26: 567-81.PubMedCrossRefGoogle Scholar
  2. 2.
    Holm JH, Frederiksen CA, Juhl-Olsen P, Sloth E. Perioperative use of focus assessed transthoracic echocardiography (FATE). Anesth Analg 2012; 115: 1029-32.PubMedCrossRefGoogle Scholar
  3. 3.
    Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma 1999; 46: 466-72.PubMedCrossRefGoogle Scholar
  4. 4.
    Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am 2010; 28: 29-56, vii.Google Scholar
  5. 5.
    Faris JG, Veltman MG, Royse CF. Limited transthoracic echocardiography assessment in anaesthesia and critical care. Best Pract Res Clin Anaesthesiol 2009; 23: 285-98.PubMedCrossRefGoogle Scholar
  6. 6.
    Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011; 364: 749-57.PubMedCrossRefGoogle Scholar
  7. 7.
    Denault AY. Difficult separation from cardiopulmonary bypass:importance, mechanism and prevention (PhD Thesis: https://papyrus.bib.umontreal.ca/xmlui/handle/1866/4241). Université de Montréal, 2010.
  8. 8.
    Piette E, Daoust R, Denault A . Basic concepts in the use of thoracic and lung ultrasound. Curr Opin Anaesthesiol 2013; 26: 20-30. Google Scholar
  9. 9.
    Toupin F, Denault A, Lamarche Y, Deschamps A. Hemodynamic instability and fluid responsiveness. Can J Anesth 2013; 60: 1240-7.PubMedCrossRefGoogle Scholar
  10. 10.
    Royse CF, Canty DJ, Faris J, Haji DL, Veltman M, Royse A . Core review: physician-performed ultrasound: the time has come for routine use in acute care medicine. Anesth Analg 2012; 115: 1007-28. Google Scholar
  11. 11.
    Scheinfeld MH, Bilali A, Koenigsberg M. Understanding the spectral Doppler waveform of the hepatic veins in health and disease. Radiographics 2009; 29: 2081-98.PubMedCrossRefGoogle Scholar
  12. 12.
    McNaughton DA, Abu-Yousef MM. Doppler US of the liver made simple. Radiographics 2011; 31: 161-88.PubMedCrossRefGoogle Scholar
  13. 13.
    Valeri CR, Dennis RC, Ragno G, Macgregor H, Menzoian JO, Khuri SF. Limitations of the hematocrit level to assess the need for red blood cell transfusion in hypovolemic anemic patients. Transfusion 2006; 46: 365-71.PubMedCrossRefGoogle Scholar
  14. 14.
    Warkentin TE. Systematic underestimation of anemia severity in postoperative patients. Transfusion 2006; 46: 317-8.PubMedCrossRefGoogle Scholar
  15. 15.
    Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18: 1440-63.PubMedCrossRefGoogle Scholar
  16. 16.
    Rudski LG, Lai WW, Afilalo J, et al . Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010; 23: 685-713. Google Scholar
  17. 17.
    Vieillard-Baron A, Caille V, Charron C, Belliard G, Page B, Jardin F. Actual incidence of global left ventricular hypokinesia in adult septic shock. Crit Care Med 2008; 36: 1701-6.PubMedCrossRefGoogle Scholar
  18. 18.
    Denault AY, Chaput M, Couture P, Hebert Y, Haddad F, Tardif JC. Dynamic right ventricular outflow tract obstruction in cardiac surgery. J Thorac Cardiovasc Surg 2006; 132: 43-9.PubMedCrossRefGoogle Scholar
  19. 19.
    Rochon AG, L’Allier PL, Denault AY. Always consider left ventricular outflow tract obstruction in hemodynamically unstable patients. Can J Anesth 2009; 56: 962-8.PubMedCrossRefGoogle Scholar
  20. 20.
    Haddad F, Couture P, Tousignant C, Denault AY. The right ventricle in cardiac surgery, a perioperative perspective: II. Pathophysiology, clinical importance, and management. Anesth Analg 2009; 108: 422-33.PubMedCrossRefGoogle Scholar
  21. 21.
    Neira VM, Gardin L, Ryan G, Jarvis J, Roy D, Splinter W. A transesophageal echocardiography examination clarifies the cause of cardiovascular collapse during scoliosis surgery in a child. Can J Anesth 2011; 58: 451-5.PubMedCrossRefGoogle Scholar
  22. 22.
    Costachescu T, Denault A, Guimond JG, et al. The hemodynamically unstable patient in the intensive care unit: hemodynamic vs. transesophageal echocardiographic monitoring. Crit Care Med 2002; 30: 1214-23.PubMedCrossRefGoogle Scholar
  23. 23.
    Alsaddique AA, Royse AG, Royse CF, Fouda MA. Management of diastolic heart failure following cardiac surgery. Eur J Cardiothorac Surg 2009; 35: 241-9.PubMedCrossRefGoogle Scholar
  24. 24.
    Deslauriers N, Dery R, Denault A. Acute abdominal compartment syndrome. Can J Anesth 2009; 56: 678-82.PubMedCrossRefGoogle Scholar
  25. 25.
    Denault AY, Couture P, Vegas A, Buithieu J, Tardif JC. Transesophageal Echocardiography Multimedia Manual - Second edition: A Perioperative Transdisciplinary Approach. New York: Informa Healthcare; 2011 .Google Scholar
  26. 26.
    Johnson BA, Weil MH. Redefining ischemia due to circulatory failure as dual defects of oxygen deficits and of carbon dioxide excesses. Crit Care Med 1991; 19: 1432-8.PubMedCrossRefGoogle Scholar
  27. 27.
    Ghosh A, Elwell C, Smith M. Review article: cerebral near-infrared spectroscopy in adults: a work in progress. Anesth Analg 2012; 115: 1373-83.PubMedCrossRefGoogle Scholar
  28. 28.
    Harel F, Denault A, Ngo Q, Dupuis J, Khairy P. Near-infrared spectroscopy to monitor peripheral blood flow perfusion. J Clin Monit Comput 2008; 22: 37-43.PubMedCrossRefGoogle Scholar
  29. 29.
    Reeves ST, Finley AC, Skubas NJ, et al. Special article: Basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2013; 117: 543-58.PubMedCrossRefGoogle Scholar
  30. 30.
    Vignon P, Dugard A, Abraham J, et al. Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit. Intensive Care Med 2007; 33: 1795-9.PubMedCrossRefGoogle Scholar
  31. 31.
    Vignon P, Mucke F, Bellec F, et al. Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents. Crit Care Med 2011; 39: 636-42.PubMedCrossRefGoogle Scholar
  32. 32.
    Denault AY, Rochon AG. Transesophageal echocardiography training: looking forward to the next step. Can J Anesth 2011; 58: 1-7.PubMedCrossRefGoogle Scholar
  33. 33.
    Denault A, Fayad A, Chen R. Focused ultrasound is the next step in perioperative care. Can J Anesth 2013; 60: 741-7.PubMedCrossRefGoogle Scholar
  34. 34.
    Beigel R, Cercek B, Luo H, Siegel RJ. Noninvasive evaluation of right atrial pressure. J Am Soc Echocardiogr 2013; 26: 1033-42.PubMedCrossRefGoogle Scholar
  35. 35.
    American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010; 112: 1084-96.Google Scholar
  36. 36.
    Lapointe V, Jocov D, Denault A. Hemodynamic instability in septic shock. Can J Anesth 2009; 56: 864-7.PubMedCrossRefGoogle Scholar
  37. 37.
    Bainbridge D, Cheng D. Stress-induced cardiomyopathy in the perioperative setting. Can J Anesth 2009; 56: 397-401.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists' Society 2014

Authors and Affiliations

  1. 1.Department of Anesthesiology, Toronto General HospitalUniversity of TorontoTorontoCanada
  2. 2.Department of Anesthesiology, Critical Care Division, Montreal Heart InstituteMontrealCanada
  3. 3.Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de MontréalMontrealCanada
  4. 4.Ultrasound Education Unit, Department of SurgeryThe University of MelbourneParkvilleAustralia

Personalised recommendations