ICUCase#4: Preload and Afterload assessment from Critical Care Echo in cardiogenic shock
- Neev Patel
- Aug 2, 2023
- 2 min read
Updated: Jul 23, 2024
60 year old male with no known history admitted to ICU for cardiogenic shock and A fib w RVR. On BiPAP and CRRT. Also on levophed, dobutamine, and amiodarone. Based on VEXUS and Critical Care Echo what do you think of preload and afterload?
1. VEXUS: IVC 2.7 cm
Hepatic Venous Doppler:
S wave reversal (on comparison with IRVD, single diastolic waveform). --> severely abnormal pattern
Portal Venous Doppler:
> 50% pulsatility --> severely abnormal pattern
Intra Renal Venous Doppler:
Discontinuous monophasic --> severely abnormal pattern
Since more than 2 severely abnormal patterns -> VEXUS grade 3 -> severe congestion Now, lets take a look at cardiac ultrasound: 1. PLAX view:
Poor windows, unstable view with respiration.
2. PSAX View:
D sign/Diastolic septal flattening + Hard to assess systolic vs diastolic in A fib here.
By reducing playback speed, diastolic flattening becomes apparent. Suggesting RV volume overload.
3. Apical 4 chamber view:
Moderately reduced EF
4. Mitral valve color doppler:
Central stream: could be functional due to hypervolemia, or structural from dilated cardiomyopathy at baseline
Likely Moderate to severe MR
5. MR Vmax:
325 cm/s
6. Tricuspid valve color doppler:
Likely moderate TR
7. TAPSE & TR Vmax:
TAPSE 12.5 mm, which is < 17 mm --> suggesting decreased RV systolic dysfunction
TR Vmax from Parasternal RV inflow view: 129 cm/s. Not so impressive
8. LVOT VTI and Cardiac Output:
Average LVOT VTI for 3 calculated waveforms-> 8.4 cm.
Suggesting low forward flow.
Calculated Stroke Volume with average HR 110 on above drips = 25 cc.
Cardiac Output 2.8 L/min
Cardiac Index 1.15 L/min/m2
To summarise:
Cardiac functions: SV 25 cc. CO 2.8 L/min, CI 1.15 L/mimn/m2.
Current drips: Levophed 0.54 mcg/kg/min Dobutamine 20 mcg/kg/min (Max dose) Amiodarone 0.5 mg/min
Current Vitals:
Now, What changes would you make in current drips?
Increase Dobutamine
Increase levophed
Decrease levophed
Add another agent
Clinical Impression:
Given both TR and moderate MR, along with volume overload. Could likely be functional murmurs.
In current scenario, above valvular regurgitations along with high afterload from levophed can explain above SV and CO.
-> Decrease Levophed is what we did!
We were able to wean down Levo and after clinical stability, could wean down dobutamine later.
Author:
Neev Patel, MD
This post brought back a really vivid memory from a few years back. We had a patient who presented with severe cardiogenic shock, and the echo findings were just textbook for understanding their hemodynamics. I remember being fascinated by how the preload and afterload assessments, specifically looking at those IVC and LV dimensions and wall motion, gave us such a clear picture of where the problem was originating and how we could best intervene https://www.justice.qld.gov.au/initiatives/liquor-gaming It wasn't just about seeing the structural issues, but truly grasping the functional impact. It’s moments like those that highlight the incredible value of point-of-care ultrasound in guiding immediate management decisions for these critically ill patients. It really solidifies why these skills are so essential…
This post really hit home. It reminded me of a few years ago when my dad was in the hospital with a severe heart condition. He was so sick, and the doctors were constantly monitoring his blood pressure and heart function. I remember seeing all those machines and lines, and trying to understand what all the numbers meant https://en.wikipedia.org/wiki/Game It was terrifying, and I honestly felt so helpless just watching. They did end up using some invasive monitoring, and I remember the nurses being so careful and explaining what they were doing, but it was still a lot to process. It’s fascinating to think about how much has advanced in this field, and how noninvasive methods are becoming more prevalent.…
Consultando calculadora de notas para calcular promedio final del colegio, el contenido del sitio fue claro y directo.