Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients: Part II
Publication Date: June 1, 2016
Last Updated: March 14, 2022
Recommendations
Preload Responsiveness
In Mechanically Ventilated Patients About to Undergo Fluid Resuscitation (Recommended for All Levels of Training).
We recommend critical care practitioners consider measuring IVC collapsibility in patients on positive pressure ventilation by bedside cardiac ultrasound (BCU) to assess fluid responsiveness prior to undergoing large volume fluid resuscitation. Any patient who has more than 15% change in vena caval diameter should be considered preload responsive. Patients with a smaller change in IVC diameter may not respond favorably to fluid resuscitation. (1B)
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In Spontaneously Breathing Patients About to Undergo Fluid Resuscitation
- We make no recommendation regarding the method of assessment of fluid responsiveness either by IVC diameter and collapsibility or other methods to assist with shock resuscitation of the spontaneously breathing patient.
- We make no recommendation regarding the method of assessment of fluid responsiveness in those with abdominal compartment syndrome.
In Patients Unable to Obtain Adequate Images With TTE (Recommended for Expert Levels of Training)
We recommend that TEE presents a reliable, low-risk, and timely solution to help the practitioner evaluate a patient’s preload responsiveness when TTE cannot be performed. (1C)
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Assessment of the LV Function
Assessment of LV Systolic Function (Recommended for All Levels)
We recommend that assessment of LV systolic function should be attempted in all patients with either preexistent or ICU-acquired cardiac disease to better understand limitations of fluid resuscitation and choice of inotropic and vasoactive medications. (1C)
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Assessment of LV Diastolic Function (Suggested for an Expert Level)
We suggest that assessment of LV diastolic function may be considered in all patients with either preexistent or ICU-acquired cardiac disease to better understand limitations of fluid resuscitation and choice of inotropic and vasoactive medications. (2C)
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RV Dysfunction
ACP (Recommended for All Levels of Training)
We recommend that BCU be used to evaluate for signs of acute RV failure due to pressure or volume overload. (1C)
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Pulmonary Hypertension (Recommended for Expert Level of Training)
We recommend that BCU should be used to measure pulmonary arterial pressures in all patients with suspected primary or secondary pulmonary hypertension provided that operator has the required training for this. (1B)
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We make no recommendation regarding the measurement of tricuspid annular plane systolic excursion (TAPSE) to assess RV motion in pulmonary hypertension, RV function, and to provide prognostic information.
Symptomatic PE (Recommended for All Levels of Training)
We recommend that in unstable patients with suspected PE, bedside cardiac ultrasonography and a venous examination of the proximal bilateral lower extremities should be considered prior to the consideration of CT. (1C)
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RV Infarct (Recommended for All Levels of Training)
We recommend that any patient suspected of RV infarction should undergo BCU. (1C)
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Septic Shock
Fluid Resuscitation in Sepsis (Recommended for All Levels of Training)
We recommend that BCU should be performed in patients with sepsis and septic shock to assess fluid responsiveness. (1C)
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LV Dysfunction in Sepsis (Suggested for All Levels of Training)
We suggest that all patients admitted for sepsis may receive BCU to evaluate for signs of LV dysfunction to help guide inotropic therapy. (2C)
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RV Dysfunction in Sepsis (Suggested for All Levels of Training)
We suggest that BCU may be performed to assess RV dysfunction in patients with sepsis to guide therapy. (2C)
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ACLS (Cardiopulmonary Resuscitation and Advanced Cardiac Life Support)
Electrocardiographic Asystole (Suggested for All Levels of Training)
We suggest that BCU may be performed during asystole to guide further resuscitative efforts. (2C)
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Pulseless Electrical Activity (Suggested for All Levels of Training)
We suggest that BCU may be performed in patients with pulseless electrical activity (PEA) to diagnose PEA and to identify potential causes of PEA and to differentiate a pseudo-PEA state with wall motion. (2C)
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Ventricular Tachycardia/Fibrillation Arrest (Recommended for All Levels of Training)
We recommend that BCU should be performed in patients with ventricular tachycardia/fibrillation arrest following return of spontaneous circulation (ROSC) to look for segmental wall motion abnormalities as a surrogate for CAD being the primary cause of cardiac arrest. (1B)
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Use of TEE During Cardiopulmonary Resuscitation (Suggested for Expert Levels of Training)
We suggest that TEE may be helpful when performed during cardiopulmonary resuscitation, especially during intraoperative cardiac arrest (in cardiac surgery patients). (1C)
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ACS
ACS and Acute Myocardial Infarction (Recommended for All Levels of Training)
We recommend that patients with suspected ACS and acute myocardial infarction (AMI) should undergo BCU. (1C)
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Pericardial Effusion/Cardiac Tamponade
Cardiac Tamponade (Recommended for Expert Levels of Training)
We recommend that BCU should be performed to diagnose cardiac tamponade and to increase the effectiveness and safety of pericardiocentesis and guide performance of the procedure. (1B)
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Pericardial Effusion (Recommended for All Levels of Training)
We recommend that BCU should be performed to accurately diagnose pericardial effusion and to identify underlying causes. (1C)
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Hemodynamic Instability
Undifferentiated Hemodynamic Instability (Recommended for All Levels of Training)
We recommend that BCU should be performed in patients with hemodynamic instability to identify underlying treatable causes and to help guide fluid resuscitation. (1B)
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Valvular Dysfunction
Murmur (Recommended for All Levels of Training)
We recommend that BCU should be performed in all patients with new murmurs. (1C)
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Mechanical Valve Dysfunction (Recommended for Expert Levels of Training)
We recommend that BCU should be performed in patients with hemodynamic instability with suspected mechanical valve dysfunction to identify other contributing causes of hemodynamic instability. Routine evaluation of mechanical valve dysfunction should best be performed by experts. (1C)
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Endocarditis (Suggested for All Levels of Training)
We suggest that patients with suspected endocarditis may be screened with BCU. (2C)
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Prosthetic Valve Endocarditis (Recommended for Expert Levels of Training)
We recommend that the evaluation for prosthetic valve endocarditis should best be performed by a trained cardiologist. A TEE can be performed in the ICU by the critical care physician if the physician has advanced training in echocardiography and is adept at performing TEE. (1B)
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Diseases of Large Vessels
Great Vessel Disease and Injury (Suggested for All Levels of Training in the Hemodynamically Unstable Patient, With Clinical Suspicion of Aortic Dissection or Disruption)
We suggest that a screening bedside TTE may be performed to evaluate the proximal aortic arch, the aortic valve, and a portion of the thoracic descending aorta in patients with suspected great vessel disease or injury if other diagnostic modalities are not immediately available. (2C)
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Chest Trauma
Blunt Chest Trauma (Suggested for All Levels of Training)
We suggest bedside TTE to exclude the presence of a significant pericardial effusion in hemodynamically unstable patients with blunt chest trauma. (2C)
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Penetrating Trauma (Recommended for All Levels of Training)
We recommend that BCU should be performed in hemodynamically stable patients with penetrating chest trauma. (1C)
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TEE (Recommended for Expert Level of Training)
Poor Visualization of Cardiac Structures
We recommend that a trained physician should perform TEE in patients with poor visualization of cardiac structures with TTE. (1B)
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The Use of Contrast (Suggested for Expert Level of Training)
RV Microbubbles
We suggest that RV agitated normal saline contrast be used in all patients where cardiac source of embolic cerebrovascular accident is suspected to rule out paradoxical emboli. (2C)
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LV Contrast 2D
We recommend that LV ultrasound contrast be used under specific circumstances to improve image quality and diagnostic capability of echocardiography. (1C)
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Diagnosis of Hepatopulmonary Syndrome in Patients Under Consideration for Liver Transplantation
We recommend that a bubble echocardiography study with agitated saline be used in favor of nuclear scintigraphy to diagnose intrapulmonary shunting in hypoxic patients with chronic liver disease to evaluate hepatopulmonary disease. (1C)
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The Use of BCU in Pediatric Patients
Cardiac Arrest—Reversible Causes
We recommend that BCU be performed to exclude reversible causes of cardiac arrest in critically ill children. (1B)
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Cardiac Arrest—Irreversible Causes
We recommend that pediatric BCU alone is insufficient to diagnose irreversible pulseless cardiac activity in cardiac arrest in critically ill children. (1C)
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Preload Responsiveness
We recommend that pediatric BCU be used in the assessment and management of hypovolemic shock to determine preload responsiveness in critically ill children. (1B)
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Suspected Cardiogenic Shock
We suggest that pediatric BCU may be used in the assessment of cardiogenic shock in critically ill children. (2C)
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Suspected Septic Shock
We make no recommendations in support of or against using pediatric BCU in the assessment of septic shock in critically ill children.
Patent Ductus Arteriosus
We suggest that practitioners with advanced levels of training may use pediatric BCU to diagnose and evaluate neonatal patent ductus arteriosus (PDA). (2C)
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Congenital Heart Disease
We suggest that pediatric BCU not to be used to evaluate or definitively diagnose congenital heart disease (CHD) in pediatric patients. (2C)
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Acquired Valvular Disease
We suggest that pediatric BCU not be used in the evaluation of acquired valvular heart disease. (2C)
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RV Dysfunction
We make no recommendation supporting or against using pediatric BCU in the assessment of patients with suspected RV dysfunction.
ECMO
We make no recommendations supporting or against using BCU in the assessment of pediatric patients on ECMO.
Recommendation Grading
Overview
Title
Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients: Part II
Authoring Organization
Society of Critical Care Medicine
Publication Month/Year
June 1, 2016
Last Updated Month/Year
August 1, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To establish evidence-based guidelines for the use of bedside cardiac ultrasound, echocardiography, in the ICU and equivalent care sites.
Target Patient Population
Patients in the ICU
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis
Diseases/Conditions (MeSH)
D014463 - Ultrasonography, D003422 - Critical Care, D016638 - Critical Illness, D007362 - Intensive Care Units, D018608 - Ultrasonography, Doppler
Keywords
critical care, ultrasound, critical illness, intensive care unit, ultrasonography
Source Citation
Critical Care Medicine: June 2016 - Volume 44 - Issue 6 - p 1206-1227
doi: 10.1097/CCM.0000000000001847