resources:clinical

Profiling, Hemodynamic
- Hepatic Congestion
FREE Exam

Profiling, Hemodynamic

flowchart TD filter_dys("(1) Bad LVEF OR (2) low CI AND low HR`") dys_hypoperf_yes["Access SVR"] dys_hypoperf_no["Assess SVI and venous congestion"] filter_dys_svi["Has SVI < 35, VR(+), VC(-)"] -- Yes --> test1 filter_dys_svi["Has SVI < 35, VR(+), VC(-)"] -- No --> test2 filter_dys -- Yes --> type_dys filter_dys -- No --> B type_dys["Dysfunctional"] --> filter_dys_hypoperf["End organ hypoperfusion?"] filter_dys_hypoperf -- Yes and SVR > 1200 --> dys_svr_high["Inotrope +/- vasodilator"] filter_dys_hypoperf -- Yes and SVR < 800 AND MAP < 65 --> dys_svr_low["Inotrope +/- vasoconstrictor"] filter_dys_hypoperf -- No --> dys_hypoperf_no

Hepatic Congestion

FREE Exam

Setup

Enter patient information
Attach EKG leads
Select phased array transducer
Choose ST UMMC 1 Echo preset

Parasternal long axis (PLAX)

Qualitative EF assessment (CLIP)
LVOT diameter (SAVE)
PLAX, during end systole
Inner edge to inner edge of aortic at base of aortic valve
Normal 1.8-2.4 (~BSA, can use as surrogate if unable to measure)
Color doppler over MV and AoV to look for regurgitation (CLIP)

Parasternal short axis (PSAX)

Qualitative EF assessment at each level
Level of papillary muscles (CLIP) - assess RV as well
Level of mitral valve (CLIP)
Level of aortic valve (CLIP)
Color doppler over tricuspid to check for TR (CLIP)

Apical four chamber (A4C)

Qualitative assessment of RV and LV size (CLIP)
Color doppler over MV, LA, and LV (CLIP)
Mitral inflow E-a (SAVE)
- A4C, mitral valve, PW doppler just inside ventricle
- Above baseline, measuring flow into the ventricle/towards the probe
- E = early diastolic filling
- A = late atrial kick
- A is just before QRS, E is before A
- E > A in normal and pseudonormal (super abnormal)
Mitral annulus TDI (SAVE)
- A4C, mitral valve, lateral annulus, TDI → PW
- A’ is just before QRS, E’ is before A’
- E’ and E occur at the same time point in the cardiac cycle
- Normal E/E’ >10
Color doppler over TV (CLIP)
TR Vmax (SAVE)
- A4C, CW doppler
- Can also be done in PSAX, CW doppler, if visible at aortic valve level
- Only if tricuspid regurgitation is present
- Surrogate for RVSP/PASP (TR max PG = RVSP + CVP)

TAPSE (SAVE)
- A4C, tricuspid valve, lateral annulus, M-mode
- Estimate visually before measuring
- Measure peak to valley
- RV specific, only free wall, no contribution from septum/LV
- Normal >1.7

Apical five chamber (A5C)

Collar doppler over LVOT and AoV (CLIP)
LVOT VTI (SAVE)
- A5C, aortic valve, PW doppler where LVOT diameter was measured
- Quantitative surrogate for stroke volume (SV)
- Trace largest flow away from probe, baseline to baseline
- Normal 18-24 in euvolemia (approx. 10x BSA)
Stroke volume variation (SAVE)
- Using doppler saved for LVOT VTI, need at least 10 beats
- Decrease sweep speed (25-35 mm/sec) to see multiple beats
- Measure SV maximum and minimum flow
- Cannot do in arrhythmia, not validated in low EF
AoV Vmax
- A5C, aortic valve, CW doppler
- If AS, SVV measurement is invalidated
- Normal <200

Subcostal (SC)

Evaluate for pericardial effusion (CLIP)
Oblique view with IVC (CLIP)
IVC collapsibility (SAVE)
- SC oblique, M-mode
- If variability, measure max and min
Hepatic vein
- IVC view, PW doppler
- Drains right atrium/IVC, transduces the pressures of the right side
- Occurs between two QRS complexes
- S = ventricular systole, actually seeing atrial diastole
- D = ventricular diastole, actually seeing atrial systole
- A = atrial kick, causes small reversal in pressure
Portal vein
- IVC view, PW doppler
- Normal vein, should have continuous flow
- “Pulsatility” or “to and fro” pattern = volume intolerance

Pulmonary

Gen Abdomen preset
6 locations - upper, mid, and lower on left and right (CLIP x6)
Evaluation for B lines
Rating - (0) = absent, (1 zone) = scattered, (>2 zones) = diffuse

Internal Jugular veins (IJ)

Linear probe, decrease depth to 5cm
Measure at HOB 0 degrees and then HOB 90 degrees
Only need one side

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