Nuno Germano

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.

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.

The Evolving Concepts of Haemodynamic Support: From Pulmonary Artery Catheter to Echocardiography and Theragnostics

Echocardiography is a non-invasive tool, aimed towards the anatomical and functional characterization of the heart. In Intensive Care it is considered nowadays as a necessary tool for patient evaluation. However, the information obtained using echocardiography is not the same as provided by other means, namely the invasive ones. In recent years there has been a significant evolution in the general concepts of haemodynamic support for the critically ill patient. In this new environment, echocardiography has gained particular relevance. In this text the new positioning of echocardiography in the light of the new concepts for hemodynamic support is described, as well as, the need for a specific formative program directed towards Intensive Care physicians. A new generation of biomarkers can also add relevant information and start a new era in haemodynamic support. They may help to further characterize the disease process, identifying patients at risk, as well as, characterize specific organ failure as well as monitoring therapy.

Tromboembolismo Pulmonar Associado a Infecção VIH

Resumo A presenca de anticorpos antifosfolipidos e frequente em doentes com infeccao VIH principalmente em fases avancadas da doenca. Apesar da elevada prevalencia de anticorpos antifosfolipidos, a sua associacao a fenomenos tromboticos e rara, estando apenas descritos alguns casos. Os autores apresentam um caso clinico cuja manifestacao inaugural de uma infeccao VIH foi um tromboembolismo pulmonar associado a presenca de anticoagulante lupico. Rev Port Pneumol 2005; XI (4): 407-412Antiphospholipid antibodies are frequently found in patients with HIV infection mainly in advanced forms of disease. Despite its elevated prevalence the association with thrombotic events is rare. The author present a clinical case of a HIV patient in which the frist manifestation of the disease was a pulmonary embolism. Rev Port Pneumol 2005; XI (4): 407-412

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

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.