Ana Paula Fernandes

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.

Echocardiography: a fundamental part of the intensive care curriculum.

The purpose of this letter is to emphasize some of the particular attributes of echocardiography, based on our experience over 20 years in its application in critically ill patients. In our opinion echocardiography is under-used, and its benefits can only truly be recognized if it is routinely applied as a diagnostic tool. In fact, it is a highly dynamic technique that permits direct visualization and assessment of all of the cardiac structures, as well as of the pulmonary artery and haemodynamic status. More than any other diagnostic tool, echocardiography allows detection of valvular disease; evaluation of systolic and diastolic function, and pericardial disease; and demonstration of intracardiac shunts and quantification thereof. Furthermore, one can calculate flows and pressures at various levels, study systole and diastole, and ultimately determine whether the data obtained are accurate, based on the dynamics of cardiac structures. Haemodynamic evaluation provides information in a just a few minutes, making it possible to initiate interventions immediately, at the level of volume repletion, cardiac contractility or peripheral resistance. Besides the primary cardiac entities (e.g. myocardial infarction, valvular disease and thrombi, etc.) that may benefit from echocardiographic evaluation, other cardiac abnormalities may also be revealed under stressful conditions. Among these, diastolic dysfunction deserves particular attention because it is quite common in those beyond middle age, and may assume great importance in a critically ill patient with sepsis, pneumonia or chronic respiratory disease. If undetected, it may determine the difference between life and death. Our group identified a highly significant correlation between the isovolumetric relaxation time (an important phase of diastole) and time of weaning from mechanical ventilation [1]. Other situations that are frequently encountered involve myocardium stunning, which may occur in diverse critical illnesses, as we mentioned before. Less common but no less important are right/left intracardiac shunts, which are often unsuspected and responsible for unexplained clinical deterioration in patients subjected to positive pressure ventilation. When a mechanically ventilated patient becomes more hypoxaemic despite efforts to improve ventilation, shunt-induced hypoxemia caused by a patent foramen ovale should be suspected, among other causes such as pulmonary embolism [2]. Only echocardiography can identify such specific abnormalities in mechanically ventilated patients, when weaning is difficult or refractory hypoxaemia is not explained by pulmonary disease alone. The main issue is that, globally, further knowledge and practice of echocardiography are required if we are to recognize its potential within the framework of general intensive care. Thus, our message is that we must first study patients using echo-cardiography, including clinical data, and then act accordingly. The contribution of echocardiography to the diagnosis and prompt treatment of many commonly overlooked situations may ultimately be associated with a decrease in morbidity and mortality. For this reason, we must promote training in echocardiography, as well as its routine use as an essential examination [3,4]. In our opinion, based on 20 years experience in echocardiography, the enormous advantages offered by this noninvasive technique renders it an indispensable tool in general intensive care units; consequently, training of physicians from specialities other than cardiology is required. Bluntly, it must become part of the intensivists curriculum.

Non invasive evaluation of central venous pressure using echocardiography in the intensive care – Specific features of patients with right ventricular enlargement and chronic exacerbated pulmonary disease

OBJECTIVES To determine the possibility of non-invasive estimation of central venous pressure (CVP) through inferior vena cava (IVC) analysis, using transthoracic echocardiography (TTE). DESIGN A prospective 3-year study. SETTING A 16-bed medical/surgical Intensive Care Unit (ICU). METHODS Patients admitted to the ICU were enrolled. CVP measurement and TTE (determining cardiac chambers dimension and left ventricular shortening fraction) with IVC analysis (maximum dimension and IVC index) were performed simultaneously. Parametric and non-parametric statistical analysis was performed to establish correlations between variables. RESULTS 560 patients were admitted to the study, including 477 in whom IVC was analysed, aging 62.2 +/- 17.3 years, a mean ICU stay 11.9 +/- 18.7 days, a APA- CHE II score 23.9 +/- 8.9 and a SAPS II score 55.7 +/- 20.4. Through linear regression analysis CVP was influenced by IVC index (p=0.001), IVC maximum dimension (p=0.013) and presence of mechanical ventilation (p=0.002). A statistically significant correlation was found between the following parameters: an IVC index < 25% and a CVP > 13 mmHg; an IVC index and a CVP 26%-50%; an IVC index > 51% and CVP < 7 mmHg; an IVC maximum dimension > 20mm and a CVP > 13 mmHg; an IVC maximum dimension < 10 mmHg and CVP < 7 mmHg. Patients with right ventricle enlargement presented a lack of agreement between IVC maximum dimension and CVP > 7 mmHg was observed, and in patients with chronic respiratory failure (who presented a high prevalence of right ventricular enlargement) a lack of agreement between IVC index > 50% and CVP < 7 mmHg was also observed. CONCLUSIONS IVC analysis is a possible way to non-invasively estimate CVP in a medical /surgical ICU. However, patients with right ventricular enlargement and admitted with chronic respiratory failure present a lack of agreement between IVC parameters and low values of CVP. IVC dimension is a marker of chronic disease and IVC index correlated better with CVP.

Avaliação não invasiva da pressão venosa central por ecocardiografia em cuidados intensivos - Particularidades nos doentes com dilatação do ventrículo direito e exacerbação de doença pulmonar crónica

Objectives: To determine the possibility of non-invasive estimation of central venous pressure (CVP) through inferior vena cava (IVC) analysis, using transthoracic echocardiography (TTE). Design: A prospective 3-year study. Setting: A 16-bed medical/surgical Intensive Care Unit (ICU). Methods: Patients admitted to the ICU were enrolled. CVP measurement and TTE (determining cardiac chambers dimension and left ventricular shortening fraction) with IVC analysis (maximum dimension and IVC index) were performed simultaneously. Parametric and non-parametric statistical analysis was performed to establish correlations between variables. Results: 560 patients were admitted to the study, including 477 in whom IVC was analysed, aging 62.2 ± 17.3 years, a mean ICU stay 11.9 ± 18.7 days, a APACHE II score 23.9 ± 8.9 and a SAPS II score 55.7 ± 20.4. Through linear regression analysis CVP was influenced by IVC index (p = 0.001), IVC maximum dimension (p = 0.013) and presence of mechanical ventilation (p = 0.002). A statistically significant correlation was found between the following parameters: an IVC index > 25% and a CVP 7 mmHg; an IVC maximum dimension 10 mmHg and CVP > 7 mmHg. Patients with right ventricle enlargement presented a lack of agreement between IVC maximum dimension and CVP 7 mmHg was also observed. Conclusions: IVC analysis is a possible way to noninvasively estimate CVP in a medical/surgical ICU. However, patients with right ventricular enlargement and admitted with chronic respiratory failure present a lack of agreement between IVC parameters and low values of CVP. IVC dimension is a marker of chronic disease and IVC index correlated better with CVP. Rev Port Pneumol 2006; XII (6): 637-658

Imunocitoma IgA. A propósito de um caso clínico

Resumo O imunocitoma e um linfoma nao Hodgkin (LNH) de celulas B, com evolucao habitualmente indolente. Representa aproximadamente 1–3% dos LNH e atinge habitualmente adultos com mais de 50 anos, podendo manifestar-se por adenomegalias, hepatomegalia, esplenomegalia e linfocitose em 15 a 30% dos casos. Raramente tem envolvimento pulmonar. Com frequencia ocorrendo picos monoclonais de imunoglobulinas, sericos, frequentemente IgM e raramente IgA. Como exemplo desta patologia apresentamos o caso clinico de um doente do sexo masculino, 52 anos, com clinica de infeccoes respiratorias bacterianas de repeticao, com necessidade de internamentos sucessivos, cuja investigacao identificou um imunocitoma IgA, estadio IV. Assumindo-se o diagnostico de um linfoma indolente, decidiu-se iniciar terapeutica profilactica com imunoglobulinas humanas poliespecificas, tendo havido diminuicao das infeccoes respiratorias. Posteriormente, a evidencia de progressao do linfoma condicionou o inicio de poliquimioterapia, com o esquema ciclofosfamida, vincristina, prednisolona (CVP) e rituximab®, tendo-se alcancado uma resposta parcial, que se manteve durante dois anos.

Prevalência e Caracterização Clínica dos Doentes com Insuficiência Respiratória Parcial Grave Internados numa UCI

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. Rev Port Pneumol 2008; XIV (3): 339-352

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.

The effectiveness of transthoracic echocardiography as a screening examination in a noncoronary intensive care unit

The authors tested the feasibility of transthoracic echocardiography (TTE) as a routine technique in a medical/surgical ICU.

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.