echocardiography in icu · echocardiography in icu. role of echo in patients with ecmo dr elena...
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Hajar auditorium Medical City
HMC Doha, Qatar
February 8‐9, 2019
ECHOCARDIOGRAPHY IN ICU
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Role of echo in patients with ECMO
Dr Elena GALLI, MD, PhD, FESCUniversity Hospital of Rennes
FRANCE
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Outline
ECMO description
Indication, controindications and complications
Echocardiographic imaging in patients with ECMO
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ECMO – definition
Spectrum of modalities able to provide cardiac and respiratorysupport, which can be used for extended period (hours to weeks).
VV –ECMO Provide support in case of isolated respiratory failure
VA –ECMO Provide support for cardiac and/or respiratory failure
VV‐ECMO VA‐ECMO
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Indications for VV-ECMORefractory respiratory failure
(PO2 < 60mmHg and/or acidosis - PH <7.2 orPO2<100% with FiO2>/=90%)
Severe bacterial or viral pneumoniaARDSAspiration syndromesPrimary graft failure after lung transplantationMassive hemoptysis or pulmonary hemorrhageSmoke inalationStatus asthmaticusAirway obstructionAlveolar proteinosisPulmonary contusion
Platts et al. JASE 2012
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Indications for VA-ECMOCardiac arrest/near-cardiac arrestCardiogenic shockInability to wean from CP bypass after cardiac surgeryPrimary graft failure after heart or heart-lung transplantationSepsis with profound cardiac depressionDrug overdose/toxycity with cardiac depressionMyocarditisArrhythmic storm refractory to other measuresPulmonary embolismIsolated cardiac traumaAcute anaphylaxis
Periprocedural support from high risk PCIChronic cardiomyopathy: bridge to VAD, bridge to transplant, bridge to decision
Platts et al. JASE 2012
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ContraindicationsABSOLUTENon recoverable diseaseIrreversible neurologic injuryAdvanced multi-organ failureContraindication to anticoagulation
Body weight > 125 Kg (difficult vascular cannulation, inadeguate flow?)
RELATIVEAge >75 ysInability to anticoagulateHigh dose immunosuppressionCPR >60 minMultiple trauma with multiple bleeding sites
Platts et al. JASE 2012
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Complications
Bleeding, Thromboembolism, sepsis
Limb ischaemia, hemolysis, mechanical failure
Intracerebral bleeding, circuit rupture, accidentaldecannulation, air embolism
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Role of Echo
PATIENT SELECTION
INSERTION AND PLACEMENT OF CANNULAS
MONITOR PROGRESS
DETECT COMPLICATION
DETECT CARDIAC RECOVERY / WEANING
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Patient’s selection
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Look for the cause of of hemodynamic instability
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Assessment of valvular function
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Assessment of valvular function
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Assessment of the inter‐atrial septum
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Assessment of the left atrium
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Assessment of the right atrium
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Assessment of the right ventricle
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PAT 60 ms
Tricuspid morphology (regurgitation/stenosis)Presence of a tricuspid prosthesis
Assessment of PW Pulmonary Doppler
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Assessment of the left heart
LVEF <20% should support the indication ofVA‐ECMO in case of associated respiratoryfailure
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Cannulation
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There are currently no recommendations on which imagingmodality is superior to guide ECMO cannulation.
VV-ECMO
2 venous cannulas:
1) One in the IVC (drainage)and the other in the SVC (reinjection)
2) Reinjection cannula in the in the RA from the IVC, the drainage cannula in the femoral vein
3) A single, dual-lumen cannulainserted into the SVC via the right internal jugular vein.
Pavlushkiv et al. Ann Transl Med 2017; 5: 70
VA-ECMO
1 venous cannula in the IVC
1 arterial cannular in the femoral/iliac artery
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SVC drainage cannula
IVC drainage cannula
Return flow orifice
Griffee MG et al. Jour of Cardioth and Vasc Anesth 2018
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VA-ECMO
Venous cannula in the IVC
Aortic cannula in the iliac artery or distal aorta.
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Utility of echo in the assessment of proper cannula positioning
193 pediatric patients supported on ECMO: 101 procedures without Echo guidance 17.8% repositioning92 procedures under Echo giodance 3.3% repositioning
Kuenzler et al. Pediatr Surg 2002
TTE vs XR for cannula positioning in pediatric patients : 33 procedures under TTE guidance 24% required readjustementXR didn’t reveal incorrect cannula positioning.
Thomas et al. Pediatr Crit Care Med 2009
XR is largely available, but lacks sensitivity in detecting cannula positioning
Echocardiography provides better spatial orientation of cannulas
XR is largely available, but lacks sensitivity in detecting cannula positioning
Echocardiography provides better spatial orientation of cannulas
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Assessment of the patient on ECMO
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1) Assessment of pericardial effusion/Tamponade
2) In case of reduced flow, look for thrombosis of the drainage cannula with 2D, PW and Colour Doppler
3) Serial assessment of LV function
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Kreik et al. J Pediatr 1995
60 pediatric patients on ECMO 7 thrombosis : 3 SVC syndromes4 incidental thrombosis detected at TTE
No specific cause for thrombosis was identified in these patients
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VA‐ECMO weaning
Reduce ECMO flow 0,5 to 1 L/minPotential increase in the risk of circuit thrombus formation!
Assess clinical/hemodynamic parameters:‐HR, BP‐Arterial waveform pulsatility‐PaO2 in the radial artery‐Changes in CVP
Assess Echo parameters like:‐VTI Ao > 10 cm‐LVEF > 20‐25%‐ S wave velocity (Sa)> 6 cm/s at the lateral mitral annulus ‐Increase in LV GLS of at least 20%
Aissaoui N et al. Crit Care Med 2015Aissaoui N et al JASE 2012
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MF, 39 yoPrimary dilated cardiomyopathyAcute HF
LVEF 10%VTI-LVOT 6 cmCO 1.8 L/min
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SOR 0.26 cm2
VR 32 ml
Very elevated LV filling pressure
PAPs 37 mmHg, butRV dysfunction
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Patients receving dobutamine 10 μg/Kg/min
Hypotension, oligo-anuria, progressive kidney and liver failure
Noradrenaline 0.5 μg/Kg/min
VA‐ECMO
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Thanks for the attention!