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Review
. 2018 Jul-Sept;30(3):385-393.
doi: 10.5935/0103-507X.20180055.

Non-invasive hemodynamic evaluation by Doppler echocardiography

[Article in Portuguese, English]
António Gaspar  1 , Pedro Azevedo  1 , Roberto Roncon-Albuquerque Jr  2
Affiliations
Review

Non-invasive hemodynamic evaluation by Doppler echocardiography

[Article in Portuguese, English]
António Gaspar et al. Rev Bras Ter Intensiva. 2018 Jul-Sept.

Abstract
in English, Portuguese

The approach for treating a hemodynamically unstable patient remains a diagnostic and therapeutic challenge. Stabilization of the patient should be rapid and effective, but there is not much room for error. This narrow window of intervention makes it necessary to use rapid and accurate hemodynamic evaluation methods. Echocardiography is the method of choice for the bedside evaluation of patients in circulatory shock. In fact, it was intensive care physicians who recognized the potential of Doppler echocardiography for the initial approach to patients in circulatory failure. An echocardiogram allows rapid anatomical and functional cardiac evaluation, which may include non-invasive hemodynamic evaluation using a Doppler study. Such an integrated study may provide data of extreme importance for understanding the mechanisms underlying the hemodynamic instability of the patient to allow the rapid institution of appropriate therapeutic measures. In the present article, we describe the most relevant echocardiographic findings using a practical approach for critical patients with hemodynamic instability.

A abordagem do doente hemodinamicamente instável constitui um desafio diagnóstico e terapêutico. A estabilização do doente deve ser rápida e eficaz, não existindo muita margem para erro. Esta estreita janela de intervenção faz com que seja necessário recorrer a métodos de avaliação hemodinâmica rápidos e precisos. A ecocardiografia constitui o método de eleição para a avaliação, à beira do leito, do doente em choque circulatório. De fato, foram os médicos intensivistas que cedo reconheceram as potencialidades do ecocardiograma com estudo Doppler para a abordagem inicial do doente em falência circulatória. O ecocardiograma permite uma avaliação cardíaca anatômica e funcional rápida, a qual pode incluir avaliação hemodinâmica não invasiva por meio do estudo Doppler. Tal estudo integrado pode fornecer dados de extrema importância para a compreensão dos mecanismos subjacentes à instabilidade hemodinâmica do doente, permitindo a instituição célere das medidas terapêuticas apropriadas. No presente artigo, propomo-nos a descrever os achados ecocardiográficos mais relevantes em uma abordagem prática e dirigida ao doente crítico com instabilidade hemodinâmica.

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Conflict of interest statement

Conflicts of interest: None.

Figures

Figure 1
Figure 1
Levels of competence in echocardiography. TTE - transthoracic echocardiography; TEE - transesophageal echocardiography. Source: Adapted from Price S, Via G, Sloth E, Guarracino F, Breitkreutz R, Catena E, Talmor D; World Interactive Network Focused on Critical UltraSound ECHO-ICU Group. Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound. 2008;6:49.(6)
Figure 2
Figure 2
Dilated cardiomyopathy.
Figure 3
Figure 3
Interventricular septum rupture under acute inferior wall myocardial infarction.
Figure 4
Figure 4
Cardiac tamponade.
Figure 5
Figure 5
Calculation of cardiac output and peripheral vascular resistance via Doppler echocardiography. LVOT - left ventricular outflow tract in parasternal long axis; TVIlvot - time-velocity integral of the flow of the left ventricle outflow tract in the parasternal long axis in the apical 5-chamber; VolEj - ejection volume; CO - cardiac output; HR - heart rate; CI - cardiac index; BodySurf - body surface; PVR - peripheral vascular resistance; MBP - mean blood pressure.
Figure 6
Figure 6
Right ventricular dilation with bulging of the interventricular septum towards the left ventricle under acute pulmonary thromboembolism.
Figure 7
Figure 7
Estimation of left ventricular filling pressures. E/A - ratio between early filling velocity E of transmitral flow and late filling velocity A in pulsed Doppler; E/Ea - ratio between the early filling velocity E of the mitral flow in the pulsed Doppler and the early diastolic velocity Ea in the tissue Doppler collected at the level of the mitral annulus; Vel TR - velocity of tricuspid regurgitation; Vol LA - left auricle volume; LVFP - left ventricular filling pressures. Source: Adapted from Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29(4):277-314.(36)
Figure 8
Figure 8
Algorithm for systematic echocardiographic evaluation of hemodynamically unstable patients. AMI - acute myocardial infarction; CO - cardiac output; PVR - peripheral vascular resistance. Source: Adapted from: Lichtenstein DA. BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill. Chest. 2015;147(6):1659-70.(29)
See this image and copyright information in PMC

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