ECHO 2013 / Management Decisions in the ICU and ER The Role of the FOCUS Echo
.pdf
Anesth Analg 2012;115:1007–28
“An invasion of armies can be resisted, but not
an idea whose time has come.”
—Victor Hugo
Anesth Analg 2012;115:1007–28
Principles Behind Goal-focused
Echo
•Concentrate on either 2D only, or 2D and color flow Doppler analysis, and to avoid formal quantification using pulsed wave or continuous wave Doppler.
•Emphasis on pattern recognition of pathology rather than extensive quantification
Higher skill-set required to perform/interpret spectral Doppler
Removing spectral Doppler also reduces the time to perform point-of-care echo
•Imaging protocol is defined by the clinical requirement
FOCUS STRUCTURAL IMAGING
•Pericardial Effusion
•Global ventricular size and function
•Right ventricular enlargement
Pulmonary embolus
•Volume Assessment
Pericardium
•Two Layers:
Visceral Layer
•Thin elastic membrane of mesothelial cells
Parietal Layer
•Thick, stiffer layer of collagen and elastic fibers
•Pericardial space
Small (~20 cc) of fluid
•Note:
Shape of a U
Never attached to cardiac chambers
Pericardium
•Functions
Limitation of intrathoracic cardiac motion
Balancing RV and LV output through diastolic and systolic interactions
Buffering of positional changes in chamber filling
Suction filling
Limitation of acute dilatation
Lubricant effects
Lymphatic/immunological functions (may prevent contiguous spread of infection)
FOCUS Echo of the Pericardium
•M-mode or 2D
Bright, dense layer of echoes (usually ~2 mm)
Inseparable from epicardial echoes
Sensitivity of detecting pericardial fluid
•20 ml may be detectable
•Up to 50 ml may be normal
FOCUS Echo of Pericardial
Effusion
|
Small |
Moderate |
Large |
Circumferential |
|
|
|
Echo (cm) |
< 1.0 |
1.0-2.0 |
> 2.0 |
Fluid (ml) |
300 |
500-700 |
>700 |
Loculated/Localized
Echo (cm) |
<0.5 |
0.5-1.0 |
>1.0 |
FOCUS Echo of the Pericardial
Effusion
“moderate circumferential pericardial effusion”
• Image from multiple views
Use off-axis views |
“localized effusion, ~2.3 cm |
|
|
Use gain setting appropriately |
around the right atrium” |
Note location and size
FOCUS Echo of the Pericardial
Effusion
• Use gain setting appropriately
Low gain for small effusions (reduce thickness of pericardium)
Strands imaged with higher gain