https://com-anest.sites.medinfo.ufl.edu/files/2015/06/ACCPGuidelines.pdf

American College of Chest Physicians/La Société de Réanimation de Langue Française Statement on Competence in Critical Care Ultrasonography

Over recent decades, echocardiography has become a pivotal diagnostic tool for the assessment of patients with hemodynamic compromise in general intensive care units (ICUs). In addition to its imaging capability, echocardiography provides a detailed cardiovascular assessment, based on the combination of real-time two-dimensional evaluation of cardiac structure and function and hemodynamic information provided by Doppler measurement of blood flow velocity. However, despite its ease of use, portability and accuracy, the diffusion of echocardiography among ICUs has been limited by various factors. We discuss here the main reasons for the slow acceptance by the critical care community of echocardiography as a first-line diagnostic tool for the evaluation of hemodynamically unstable patients. One of these reasons is probably the absence, in most countries, of a training program in echocardiography specifically dedicated to intensivists. We report recent French experience in the organization of specific echocardiographic certification aimed at intensivists and anesthesiologists. We strongly believe that a broader use of echocardiography would be beneficial in terms of diagnostic capability and patient management. Therefore, we would like to involve colleagues from other countries and the European Society of Intensive Care Medicine in defining the objectives of echocardiography training for intensivists and in organizing postgraduate courses and training programs aimed at developing the use of echocardiography in ICUs. This would allow the current “evolution” in mentalities to become a true “revolution” in our daily practice.

Echocardiography in the intensive care unit: from evolution to revolution?

Integrating lung ultrasound in the hemodynamic evaluation of acute circulatory failure (the fluid administration limited by lung sonography protocol)

RV performance is difficult to evaluate, given its geometry, interrelationship with the left ventricle, and sensitivity to alterations in pulmonary pressure. This article focuses on some of the challenges related to the assessment of RV function in the setting of the RV’s unique anatomic, physiologic, conventional and newer echocardiographic aspects, and therapeutic implications. The majority of proposed methods of echocardiographic assessment of RV function are based on volumetric approximations of the RV. Such approaches have inherent limitations, first as volume-related measures such as EF are load dependent, second because of the complex geometry of the RV. The issue of RV geometry is usually overcome using geometry-independent parameters such as tricuspid annular excursion and the Tei index. The recent introduction of real-time three-dimensional echocardiography and myocardial imaging echocardiography (tissue Doppler imaging, 1D-strain and 2D-strain echocardiography) implied a great progress in echocardiography. Tissue Doppler imaging allows the quantitative assessment of RV systolic and diastolic function by means of measurement of myocardial velocities. Strain measurements have been shown to correlate well with sonomicrometry segment length measurements both in the inflow and outflow tract of the RV and under different loading conditions. Other findings have been reported in chronic and acute clinical settings. Standard and novel echocardiographic methods of assessment of RV size and performance can help clinicians in the treatment of acute and chronic RV failure and contribute to a better understanding of the peculiar chamber-related functional mechanisms in the context of ventricular interdependent independency.

Do we have two hearts? New insights in right ventricular function supported by myocardial imaging echocardiography

Non-invasive evaluation of left ventricular filling pressure has been scarcely studied in critically ill patients. Accordingly, we prospectively assessed the ability of transoesophageal echocardiography (TEE) Doppler to predict an invasive pulmonary artery occlusion pressure (PAOP) ≤ 18 mmHg in ventilated patients. During two consecutive 3-year periods, TEE Doppler parameters were compared to right heart catheterisation derived PAOP used as reference in 88 ventilated patients, haemodynamically stable and in sinus rhythm (age: 63 ± 14 years; simplified acute physiologic score (SAPS) II: 45 ± 12). During the initial period (protocol A), threshold values of pulsed-wave Doppler parameters to predict an invasive PAOP ≤ 18 mmHg were determined in 56 patients. Derived Doppler values were prospectively tested during the subsequent period (protocol B) in 32 patients. In protocol A, Doppler parameters had similar area under the receiver operating characteristic (ROC) curve. In protocol B, mitral E/A ≤ 1.4, pulmonary vein S/D > 0.65 and systolic fraction > 44% best predicted an invasive PAOP ≤ 18 mmHg. Lateral E/E' ≤ 8.0 or E/Vp ≤ 1.7 predicted a PAOP ≤ 18 mmHg with a sensitivity of 83% and 80%, and a specificity of 88% and 100%, respectively. Areas under ROC curves of lateral E/E' and E/Vp were similar (0.91 ± 0.07 vs 0.92 ± 0.07: p = 0.53), and not significantly different from those of pulsed-wave Doppler indices. TEE accurately predicts invasive PAOP ≤ 18 mmHg in ventilated patients. This further increases its diagnostic value in patients with suspected acute lung injury/acute respiratory distress syndrome.

/pdf/echocardiographic-assessment-of-pulmonary-artery-occlusion-1g4n93v2o5.pdf

Echocardiographic assessment of pulmonary artery occlusion pressure in ventilated patients: a transoesophageal study

Transesophageal pulsed Doppler echocardiography of pulmonary venous flow to assess left ventricular filling pressure in ventilated patients with acute respiratory distress syndrome

The appropriateness of psychotropic prescriptions in the elderly is a major quality-of-care challenge at hospital. Quality indicators have been developed to prevent inappropriate psychotropic prescriptions. We aimed to select and automatically calculate such indicators, from the Bordeaux University Hospital information system, and to analyze the appropriateness of psychotropic prescription practices, in an observational study. Experts selected indicators of the appropriateness of psychotropic prescriptions in hospitalized elderly patients, according to guidelines from the French High Authority for Health. The indicators were reformulated to focus on psychotropic administrations. The automated calculation of indicators was analyzed by comparing their measure to data collected from a clinical audit. In elderly patients hospitalized between 2014 and 2015, we then analyzed the evolution of the appropriateness of psychotropic prescription practices during hospital stay, using methods of visualization, and described practices by considering patients’ characteristics. Two indicators were automated to detect overuse and misuse of psychotropic drugs. Indicators identified frequent inappropriate drug administrations, but practices tended to become more appropriate after quality-of-care improvement actions. In the majority of patients (85%), there was no inappropriate administration of psychotropic drugs during hospital stay; for the remaining 15% with at least one inappropriate administration, physicians tended to limit overuse or misuse during hospital stay. Inappropriate administrations were more frequent in patients suffering from psychiatric disorders, dependence and associated complications or morbidities. The automated indicators are structuring tools for the development of a drug prescription monitoring system. Inappropriate psychotropic administrations were limited by physicians during hospital stay; some inappropriate prescriptions might be explained by clinical characteristics of patients.

/pdf/appropriateness-of-psychotropic-drug-prescriptions-in-the-5brnu0411d.pdf

Appropriateness of psychotropic drug prescriptions in the elderly: structuring tools based on data extracted from the hospital information system to understand physician practices

Véronique Gilleron

Papers

Transesophageal pulsed Doppler echocardiography of pulmonary venous flow to assess left ventricular filling pressure in ventilated patients with acute respiratory distress syndrome

Appropriateness of psychotropic drug prescriptions in the elderly: structuring tools based on data extracted from the hospital information system to understand physician practices