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haemodynamic monitoring using echocardiography: a trial 2

added by Emmel

haemodynamic monitoring using echocardiography: a trial 2
Comments
Posted By: ohtusabes (936 days ago)

Well Diego... if U can´t go to Europe you tell me/us what news says
in this courses! ahaha

Best my friend
Pablo

Posted By: diego (936 days ago)

Unfortunately you live so far... In the other flip of the globe so to
speak
If someday you decide to come in Europe just let me know .
As i told you in pvt mail
We have a lot of courses designed for
intensivists ECHODYNAMICS IN CRITICALLY ILL

Posted By: ohtusabes (936 days ago)

In TTE with supraesternal view descending aorta is visible most of
times...and VTI in this level seems a good surrogate!
Ascending
aorta is more difficult in TTE but if signal is good this VTI takes
into account subclavian and carotid flow lost in descending aorta!/>
Thanks for your feedback,
Pablo

Posted By: diego (936 days ago)

YES PABLO I AGREE WITH YOU . IN ACTUAL FACTS END SISTOLIC VOLUME
MUST
BE TAKEN IN ACCOUNT . I USED SOMETIMES DESCENDING AORTIC
FLOW AS
A SURROGATE OF AORTIC FLOW CALCULATED AT THE OUTPUT
LEVEL . OBVIOUSLY
YYOU MUST TAKE IN ACCOUNT THE AMOUNT OF BLOOD
GONE AWAY TOWARD
SUBCLAVIAN ARTERIES AND ANONIMA ARTERY . THERE
ARE SOME DEVICES LIKE
CARDIO Q OR HEMOSONIC WHO USE THE DOPPLER
SIGNAL THRU DESCENDING AORTA
AND A DEDICATED SOFTWARE CAN CONVERT
ABF INTO CO . OTHERWISE USING
TEE YOU CAN ESTIMATE BLOOD FLOW
THRU DESCNDING AORTA FOR A SEMI
QUANTITATIVE EVALUATION
HOPE
I EXPLAINED MY POINT OF VIEW FOR THOSE CASES WHERE FLOW ACROSS/>LVOT CAN'T BE ACCURATELY EVALUATED

Posted By: ohtusabes (936 days ago)

Hi Diego and Jörg.

Thank you very much for your answer. I
am thinking in VTI of mitral valve and looks simple but...still don´t
contemplate what happens in forward flow because part of the filling
volume ultimately is lost at aortic closure.
And VTI of
ascending aorta...? could be more representative?

Best for
both
Pablo

Posted By: diego (936 days ago)

Hi pablo I appreciate your feedbacks . You raised a very interesting
issue about LVOT VTI
in case of aortic stenosis and or
regurgitation . In those cases I use the same equation applied to
mitral
valve . In case transmitral flow is totally normal ( no
mitral regurgitation or very small regurgitation ) THE FLOW ACROSS THE
MITRAL VALVE COULD BE EMPLOYED AS A SECOND CHOICE IN ORDER TO
INVESTIGATE THE ADEQUACY OF SV ( SD ) .... Unfortunately we know that
very very often AORTIC VALVE ABNORMALITIES ARE ASSOCIATED TO MITRAL
VALVE ABNORMALITIES .
Anyway ( summarizing ) when the flow across
aortic output tract is inaccurate , I use the interrogation of the
flow across mitral valve .
I hope I helped you pablo
Ciao
:)

Posted By: ohtusabes (936 days ago)

Hello my friends.
Following Diego comments some work groups have
used directly VTI of LVOT alone and its variation with therapy to
guide hemodinamics...and seems to be good and why not? it is a good
surrogate of CO...or better! because unlikely with LVOT, SV and CO,
VTI don´t change with body surface area and this is great! less
calculations and less error! I think it is a tool that makes simple
the estimation of forward flow.

One question for both: />What happens if moderate to severe aortic regurgitation is present?
what must we use in that case? (assuming that VTI and all calculated
with it are invalid because in every sistole the forward flow in LVOT
are overestimated due to regurgitant volume in AR that sum...but in
reality it is lost at Aortic valve close..)

It is great
the exchange of opinions. I learn a lot from both! Thank you very
much!

Best
Pablo

Posted By: diego (938 days ago)

Hi again friends I must admit the VTI EVALUATION
PER SE , DOES
OFFER A BUNCH OF INFOS .
I APPRECIATE A LOT THE PAPER YOU SENT ME
PABLO
VTI ( FLOW EVALUATION RATHER THAN OUTPUT
EVALUATION )
IT' S A PRECIOUS TOOL FOR THE ICU PHISICIAN
SHAPE VTI PEAK
VELOCITY ... OPEN UP A HUGE WINDOW
IN HEMODYNAMIC EVALUATION .

WHEN YOU HAVE A NORMAL VALVULAR APPARATUS
THE EVALUATION OF
THE VTI IT'S EVEN MIRE
THAN OUTPUT EVALUATION
WHEN I HAVE 16
of VTI VALUE WHY SHOULD I GET THE
OUTPUT IN PUMP EFFICIENCY
EVALUATION????
Really great paper pablo
And keep on Jorg .
Keep workin' this way

Posted By: Emmel (938 days ago)

Hello Pablo!!

I have learned a lot by your last articles
and your experienced comments you has given to many of my vids. In
this vid - you´re right - I tried to use all of yours and diego´s
tipps and hints for evaluation of fluid responsiveness and approach to
cardiac output.
...and it works much better than in the first
trial. In that time of first trial I have to confess that I didn´t
have a good conception for haemodynamic approach/ measurement.
So
thank you very much for teaching and sharing your experiences in
ICU-settings and "echodynamic".
In that vid I tried to use
LVOT-VTI-variation like you do (like DPP) for estimation of fluid
responsiveness: after fluid challenge I could see a distinct decrease
of LVOT-VTI-undulation.

Once mor sorry for that poor
quality of that vid (I don´t know why I have such a distinct lost of
quality after conversion in avi-format since 5 days).

Best
wishes,

Jörg.

Posted By: ohtusabes (938 days ago)

Hello Jörg and Diego:

Congratulations Jörg! You did a
great job...and you used an integrative approach with thoracic US and
fluid responsiveness index.
If you think in the late article I
send you...without a lot of calculations you know that patient have
high cardíac output... VTI more than 22 cm and tachycardia... thats
all!
And this patient sure benefits with fluids and vasopresor
therapy (hypercontractility because low afterload of LV and
hypovolemia likely).
This trial is much much better than trial
1...and this mean you are doing a great learning job!/>Congratulations!

Best
Pablo

Posted By: Emmel (939 days ago)

Thanks a lot! ...and sorry for poor quality of that clip. Actually I
have some problems in conversion of my echoclips in avi-format: the
converted clips running too fast and I have a distinct lost of quality
after conversion.

Thanks a lot and best regards.

Posted By: diego (939 days ago)

Jorg GREAT JOB YOU DID ..... nevertheless I couldn't evaluate all
snapshots of this clip ....some images goes forward too fast
I
appreciate the evaluation of LVEDP and the combination of M Mode and
color CFM in the evaluation of the VP
You did wonderfully man/>ciao


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Emmel

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Added: 18-02-2012
Runtime: 0m 45s
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Description

about 60 y old patient with condition after operation of carcinoma of pancreas and chemotherapy. Actually the patient was admitted to our ER with severe oedema of lower limbs: no thromboses of IVC or deep lower veins of both legs or V. iliacae. We found a severe lack of proteins, especially of albumin. The patient was hypoton, tachycardiac and weak. No fever, no new heart murmur. in TTE I found a hyperdynamic heart. Approach to cardiac output demonstrated a cardiac output of about 11,2 l/min (LVOT-diameter 19 mm, LVOT-VTI 42 cm, LVOT-velocity 1,76 m/s, heart rate 96-110/min). There was a increase of flow in aortic valve looking like low-grade aortic stenosis, but the dimensionsless index was near 1,0 (0,97) showing that there is no aortic stenosis (AV Vmax 2,2 m/s, PGmean 11,2 mmHg). There was also a midventricular gradient and distinct collaps of IVC; LVOT-VTI-variation was > 13% (I used that variation instead of delta pulse pressure-variation, because I did that echocardiography before tapping an artery) There wasn´t an incease of LVEDP (E/A 0,88, E/E`about 6 mmHg, velocitiy-prolongation about 0,37 - 0,42 m/s, E´-velocity 0,15 m/s). No us-b-lines or effusion of pleura. After fluid-challenge despite of the severe oedema there was a stabilisation of haemodynamic.


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