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COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

Hemodynamic monitoring provides the basis for the optimization of cardiovascular dynamics in intensive care medicine and anesthesiology. The Journal of Clinical Monitoring and Computing (JCMC) is an ideal platform to publish research related to hemodynamic monitoring technologies, cardiovascular (patho)physiology, and hemodynamic treatment strategies. In this review, we discuss selected papers published on cardiovascular and hemodynamic monitoring in the JCMC in 2017.

Hemodynamic monitoring is essential in critically ill patients. In this regard, the Journal of Clinical Monitoring and Computing (JCMC) has become an ideal platform for publishing cardiovascular and hemodynamic monitoring-related research, as reflected by an increasing number of articles related to this topic and published in the recent years. To highlight this new progress, every New Year the journal prints a descriptive review on some important papers published last year in the JCMC and related to blood, cardiovascular function and hemodynamic monitoring.

We sought to compare the inferior vena cava diameter measured by transthoracic echocardiography and by transesophageal echocardiography in human and animals. Transthoracic echocardiography yielded lower inferior vena cava diameter values than transesophageal echocardiography. Adult and pediatric intensivists should pay attention to the risk of false measurement of the inferior vena cava anterior-posterior diameter that may be due to compression of the inferior vena cava by the sonographic probe when the subxiphoid view is used., (Copyright © 2011 Wiley Periodicals, Inc.)

In 2009, the Critical Care NetWork of the American College of Chest Physicians (ACCP) in partnership with La Société de réanimation de langue française (SRLF) selected a panel of experts to characterize competence in critical care ultrasonography (CCUS) and suggest a consensus statement on competence in CCUS. CCUS may be divided into general CCUS (thoracic, abdominal, and vascular), and echocardiography (basic and advanced). For each component, the experts defined the specific skills that the intensivist should acquire to be competent in that aspect of CCUS. They, also, defined a reasonable minimum standard statement to serve as a guide for the intensivist in achieving proficiency in the field. The present article focuses on the consensus statement concerning the evaluation of the competences (basic level) in critical care echocardiography.

In intensive care unit the information managed by echocardiography is valuable. It allows often to facilitate the hemodynamic assessment of a instable patient and to guide rapidly the diagnostic track and hence his management. In this article we exhibit the different parameter, which could be obtained by this technique and present some situations in intensive care unit, in which echocardiography brings an uncontestable utility. Considering this approach as essential for a modern intensive medicine, we think that an intensivist should know to use this tool, so permitting to obtain at any time a necessary monitoring.

In patients who are mechanically ventilated, the correlation between inferior vena cava diameter (IVCD) measurements and mean right atrial pressure (RAP) varies in the literature. The purpose of this study was to test if the correlation between IVCD and RAP measurement in patients who are critically ill depends on the transthoracic echocardiography (TTE) methodology used. Twenty patients who were critically ill, sedated, and required respiratory support were prospectively studied by TTE during mechanical ventilation in a controlled mode. The TTE measures of IVCD were made, using methods previously cited. First, IVCD was measured at end-expiration and end-diastole, with ECG synchronization, using the M-mode, on short-axis view 2 cm below the right atrium. Second, IVCD was assessed at end-expiration, without ECG synchronization, using the 2-dimensional long-axis view at the same location. RAP was measured simultaneously by using a central venous catheter positioned in the superior vena cava. All measurements were taken in the supine position. IVCD at end-expiration and end-diastole, with ECG synchronization, using the M-mode, and IVCD at end-expiration, without ECG synchronization, using the 2-dimensional long-axis view, correlate linearly with RAP (0.81, P <.0001 and 0.71, P =.0004). Mean bias between the 2 TTE methods (Bland-Altman analysis) was 1.6 mm (SD +/- 2.03 mm). In conclusion, this study confirms that variation of correlation between TTE IVCD measurement and RAP depends on the ultrasonographic methodology used and the timing of measurement during the cardiac cycle. IVCD at end-expiration and end-diastole, with ECG synchronization, using the M-mode (IVCD-MM) correlates more satisfactory with RAP than with IVCD at end-expiration, without ECG synchronization, using the 2-dimensional long-axis view, in patients during mechanical ventilation.

Objective: The present study investigates whether ScvO2 variations induced by passive leg raising (PLR) are able to predict fluid responsiveness (FR) in mechanically ventilated patients. Design: A monocentric prospective clinical study. Setting: An intensive care division in a tertiary hospital. Patients: The inclusion criteria were elective postoperative cardiac surgery patients who were over 18 years old, deeply sedated, mechanically ventilated and needed volume expansion (VE). Fluid responders (R) were defined as patients who increased their left ventricular outflow tract velocity time integral (VTI) ≥15% after VE. Intervention: In patients included in this study, continuous ScvO2 monitoring (CeVOX device, Pulsion Medical Systems) and VTI (transthoracic echocardiography) were measured simultaneously before and during a PLR test and before and after VE (with 500 ml of saline). Measurements and main results: Thirty‐three consecutive patients were included in this study. In 15 patients with a positive PLR test (increase in VTI ≥15%), ScvO2 increased during PLR by 9 ± 4%. In the 18 patients with a negative PLR test, ScvO2 did not significantly change during PLR. VE increased ScvO2 by 9 ± 6% and 2 ± 4% in responders and nonresponders, respectively. If ScvO2 increased by >4% during the PLR test, then a positive VTI response (≥15%) was diagnosed with a sensitivity of 93% (68–99%) and a specificity of 94% (63–99%) (Area under the receiver operating characteristic curve 0.92 ± 0.58, p < 0.05). Moreover, ScvO2 variations were able to distinguish responders to VE from nonresponders to VE with a sensitivity of 87% (68–99%) and a specificity of 89% (63–99%) (Area under the receiver operating characteristic curve 0.89 ± 0.07, p < 0.05). Conclusions: ScvO2 variation induced by PLR is a reliable, minimally invasive parameter for predicting FR at the postoperative cardiac surgery bedside of mechanically ventilated, critically ill patients. [ABSTRACT FROM AUTHOR]

Objective: To optimize enhancement of pulmonary arteries and facilitate diagnosis of pulmonary embolism (PE), modern computed tomography angiography (CTA) contains a contrast bolus tracking system. We explored the diagnostic accuracy of the time-intensity curves given by this automated system to identify right ventricular dysfunction (RVD) in acute PE. Methods: 114 CTAs with a diagnosis of PE were reviewed. RVD was defined as right-to-left ventricular diameter ratio of 1 or greater. Four parameters on time-intensity curves were identified. Parameters between CTAs with and those without RVD were compared with the Wilcoxon rank-sum test. The ability of the four parameters to discriminate patients with RVD was explored by compiling the area under the operating curves (AUC). Results: The time needed by the contrast media to reach the pulmonary artery [8 seconds (IQR: 7–9) versus 7 seconds (IQR: 6–8), p<0.01], the time needed to reach 40 Hounsfield units (HU) [11 seconds (IQR: 8.5–14) versus 9.5 seconds (IQR: 8–10.5), p<0.01], and the contrast intensity reached after 10 seconds [19 HU (IQR: 4–67) versus 53 HU (IQR: 32–80), p<0.05] were all statistically different between CTA with and CTA without RVD. Those three parameters changed gradually across severity categories of RVD (p<0.05 for trend). Their AUC to identify RVD ranged from 0.63 to 0.66. The slope of contrast intensity over time was not informative: [31 HU/s (IQR: 20–57) in CTA with, compared to 36 HU/s (IQR: 22.5–53) in CTA without RVD, p = 0.60]. Conclusion: Several parameters of the time-intensity curve obtained by the bolus tracking system are associated with RVD assessed on CTA images. Of those, the time needed to reach a predefined threshold seems to be the easiest to obtain in any CTA without additional processing time or contrast injection. However, the performance of those parameters is globally low. [ABSTRACT FROM AUTHOR]

Conflicting results have been found regarding correlations between right atrial pressure (RAP) and inferior vena cava (IVC) diameter in mechanically ventilated patients. This finding could be related to an increase in intra-abdominal pressure (IAP). This study was designed to clarify whether variations in IVC flow rate caused by positive pressure ventilation are associated with changes in the retrohepatic IVC cross-section (ΔIVC) during major changes in volume status and IAP. Nine pigs were anesthetized, mechanically ventilated and equipped. IAP was set at 0, 15 and 30 mmHg during two conditions, i.e. normovolemia and hypovolemia, generated by blood removal to obtain a mean arterial pressure value lower than 60 mmHg. At each IAP increment, cardiac output, IVC flow and surface area were respectively assessed by flowmeters and transesophageal echocardiography. At normal IAP, even in presence of respiratory changes in IVC flows, no ΔIVC were observed during the two conditions. At high IAP, neither ΔIVC nor modulations of IVC flow were observed whatever the volemic status. The majority of animals with an IVC area of less than 0.65 cm2 showed evidence of IAP greater than RAP values. Negative RAP–IAP pressure gradients were found to occur with an IVC area of less than 0.65 cm2, suggesting that IVC dimensions determined using standard ultrasound techniques may indicate the direction of the RAP–IAP gradient. The clinical relevance of the present findings is that volume status should not be estimated from retrohepatic IVC dimensions in cases of high IAP. [ABSTRACT FROM AUTHOR]

Background: The number of nonagenarians is rising dramatically. These patients often develop severe aortic stenosis for which transcatheter aortic valve implantation (TAVI) is an attractive option. The aim of this study was to analyze the outcome of TAVI performed in a cohort of nonagenarian patients. Methods: Between August 2008 and November 2012, 23 consecutive patients in their 90th year of age or older underwent TAVI in our institution after having been assessed by the local heart team. Data concerning baseline characteristics, procedural details and outcome were prospectively entered into a dedicated database. Transthoracic echocardiography and clinical follow-up were performed pre-procedure, at discharge, at 6 and 12months and then annually post TAVI. Results: Patients were male in 52% with a mean age of 90.3±2.3years. Mean logistic EuroSCORE and STS score were 26.6±14.5% and 8.7±2.9%, respectively. Transcatheter heart valve (THV) could be implanted in all but one patient. Mortality at 30days was 8.7% overall and 4.8% for transfemoral approach. At 30days the rate of stroke was 4.3%, paravalvular leak grade ≥2 was 8.7%, life-threatening bleeding was 13.0% and pacemaker implantation was 13%. Device success was 73.9%. The rate of all-cause mortality increased to 27.3% at one-year follow-up and 42.8% at a median follow-up of 417days. Conclusions: TAVI is safe and effective even in a selected population of nonagenarians. Consequently, these patients should not be refused such a procedure based only on their age. Multi-disciplinary assessment is essential in order to properly select candidates. [ABSTRACT FROM AUTHOR]