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Review of a Large Clinical Series: Focused Bedside Echocardiography in the Surgical Intensive Care Unit: Comparison of 3 Methods to Estimate Cardiac Index
Mark Gunst, Kazuhide Matsushima, Jason Sperry, Vafa Ghaemmaghami, Melissa Robinson, Terence O'Keeffe, Randall Friese and Heidi Frankel J Intensive Care Med 2011 26: 255 DOI: 10.1177/0885066610389973 The online version of this article can be found at: http://jic.sagepub.com/content/26/4/255

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Review of a Large Clinical Series

Journal of Intensive Care Medicine 26(4) 255-260 The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0885066610389973 http://jicm.sagepub.com

Focused Bedside Echocardiography in the Surgical Intensive Care Unit: Comparison of 3 Methods to Estimate Cardiac Index

Mark Gunst, MD1, Kazuhide Matsushima, MD2, Jason Sperry, MD3, Vafa Ghaemmaghami, MD4, Melissa Robinson MD5, Terence OKeeffe MD6, Randall Friese MD, FCCM7, and Heidi Frankel, MD, FCCM8

Abstract We sought to determine which of 3 methods used to evaluate cardiac index (CI) is the most accurate using focused bedside echocardiography (ECHO). We hypothesized that the fractional shortening (FS) method would provide a more accurate estimate of CI than the left ventricular outflow tract/velocity-time integral (LVOT/VTI) or Simpsons methods. This was a prospective observational cohort study conducted in the surgical ICU of an urban level 1 trauma center utilizing all patients with a pulmonary artery catheter (PAC) in place. Three surgical intensive care unit (SICU) faculty and 3 fellows underwent focused cardiac ultrasound training. Focused ECHO examsbedside echocardiographic assessment in trauma/critical care (BEAT) were performed using the Sonosite portable ultrasound device (Bothall, Washington). Stroke volume (SV) measurements were prospectively obtained on all trauma/SICU patients, with a PAC in place, using FS, LVOT/VTI, and Simpsons methods. The investigators were blinded to the PAC data. From each measurement, CI was calculated and categorized as low, normal, or high, based on a normal range of 2.4 to 4.0 L/min per m2. Each CI obtained from the PAC was similarly categorized. The association between the BEAT and PAC estimates of CI was evaluated for each method using chi-square goodness of fit. Eighty five BEAT exams were performed on consecutive SICU patients, 56% were on trauma and 44% on emergency general surgery patients. There was a statistically significant association between the CI estimate using the FS method (P .012), but not the LVOT/VTI (P .33) or Simpsons method (P .74). Our data showed a significant association between the PAC estimate of CI and our estimate using the FS method. The other methods were difficult to obtain, subjective, and inaccurate. Fractional shortening was the method of choice to estimate CI for the BEAT exam performed by intensivists in SICU patients. Keywords ultrasonography, echocardiography, surgical ICU, trauma
Received May 29, 2009. Received Revised December 31, 2009. Submitted January 11, 2010.

Introduction
Traditional resuscitative efforts for critically ill and injured patients relied on a pulmonary artery catheter (PAC) as a guide for goal-directed interventions. Recent evidence, however, suggests that PAC-guided resuscitation may not improve outcome in many patients and may lead to increased complications.1-3 In light of these data, clinicians have sought other less-invasive methods to obtain hemodynamic information in order to optimize the care of the critically ill and injured patient.4-10 Arterial pressure waveform analysis has been used to generate stroke volume (SV) and cardiac output readings in postoperative cardiac surgery patients.11,12 However, evidence of the accuracy and reliability of this monitoring device is conflicting and limited to this patient

Wilford Hall Medical Center, San Antonio, USA Penn State Milton S. Hershey Medical Center, Pennsylvania, USA 3 University of Pittsburgh Medical Center, Pittsburgh, USA 4 Banner Good Samaritan Medical Center, Arizona, USA 5 Department of Cardiology, University of California Davis Medical Center, Sacramento, USA 6 University Medical Center, Arizona, USA 7 University of Arizona, USA 8 Department of Surgery, Division of Burn / Trauma / Critical Care, University of Texas Southwestern Medical Center, Dallas, USA
2

Corresponding Author: Heidi Frankel, Penn State Milton S. Hershey Medical Center, Mail Code H075 Room C5520, 500 University Drive, PO Box 850, Hershey, PA 17033, USA Email: hfrankel@hmc.psu.edu

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256 population.13-15 Therefore, this and other minimally invasive monitoring devices have not gained widespread acceptance in the critical care community. Bedside echocardiography (ECHO) has become more commonly used by intensivists to evaluate cardiac function in critically ill trauma and surgical patients. Bedside ECHO performed by the treating intensivist allows for a noninvasive means to obtain hemodynamic parameters in critically ill patients. Our group has previously described the BEAT exam, the Bedside Echocardiographic Assessment in Trauma / Critical Care.7 This exam provides a rapid, focused evaluation of hemodynamic parameters through both a subjective and objective assessment of cardiac function and volume status. We have shown that intensivists can learn bedside ECHO and apply this technology in the intensive care setting. Furthermore, cardiac index (CI) and central venous pressure (CVP) estimates obtained from the BEAT exam correlate with those from a PAC in critically ill surgical intensive care unit (SICU) patients.7 Although we have shown that the CI estimates obtained using fractional shortening (FS) correlate with the CI obtained from a PAC, there are 3 methods commonly used to evaluate CI using bedside ECHO; FS, left ventricular outflow tract/ velocity-time integral (LVOT/VTI), and Simpsons method. Currently, there is no evidence demonstrating which method, when performed by intensivists at the bedside, provides the most accurate estimate in SICU patients who may provide unique challenges to imaging due to chest trauma, large volume resuscitation, obesity, tachycardia, and mechanical ventilation. The purpose of this study was to compare CI estimates obtained using the FS, LVOT/VTI, and Simpsons methods with those from a PAC. The specific goal was to define which of the 3 methods, when performed by intensivists at the bedside, best correlate with the gold standard PAC in patients in shock.

Journal of Intensive Care Medicine 26(4) at the University of Texas Southwestern Medical Center and Parkland Memorial Hospital approved this study and waived the need for informed consent.

Data Collection
Demographic and baseline admission data, ventilator status, etiology of shock, and vasoactive medication requirements were collected and recorded. Physiologic data including heart rate and rhythm, mean arterial pressure, and hemoglobin level were also recorded. Pulmonary artery catheter (Edwards Lifesciences CCOmbo Volumetrics Pulmonary Artery Catheter, Irvine, California)-derived hemodynamic variables including CI were obtained in triplicate immediately prior to performing each examination and were recorded on a standardized datacollection sheet. Investigators were blinded to all PAC data. Bedside ECHO (BEAT exam) was performed by 1 of 6 investigators who were surgical critical care fellows3 or attending surgical intensivists.3 Clinical ultrasound experience ranged from 5 to 15 years, and prior instruction was limited to the FAST course provided by the American College of Surgeons. Prior to initiation of the study, all investigators completed a 2-day Focused Cardiac Ultrasound at Bedside training seminar. This course consisted of a didactic and practical component on the use of limited transthoracic ECHO under the direction of a board-certified cardiologist with advanced ECHO training. Participants were instructed on normal anatomy and echocardiographic views including the procedures to estimate CI using FS, LVOT/VTI, and Simpsons methods. The investigators derived the BEAT exam and established their competence through performance of the exam on normal volunteers. One or more of the investigators performed the ECHO exam within 24 hours of placement of the PAC and immediately after acquisition of catheter-derived CI. All exams were performed at the patients bedside with the SonoSite Titan portable ultrasound device (Bothell, WA), using a 5-2 MHz cardiac ultrasound probe. Device settings (ie, depth, gain) were adjusted as needed to improve image quality. At the conclusion of each exam, the investigator as well as an offsite cardiologist determined whether the images obtained from each method were of sufficient quality to allow a determination of the patients CI.

Materials and Methods

Prior to enrolling study participants, each of the investigators conducted the BEAT exam on 6 normal volunteers. The BEAT exam was performed in its entirety, including measurement of SV and calculating the CI using all 3 methods. These preliminary exams lead to consistent image acquisition among all investigators. This study is a prospective observational cohort analysis of consecutively admitted SICU patients at our urban level 1 adult trauma and tertiary care referral center over a 6-month period. All patients with a PAC in place for less than 24 hours were screened for enrollment in the study, and all PACs were placed at the discretion of the attending physician and used to guide resuscitation of shock. By protocol, all blunt-injured patients requiring pressors received PACs. Patients were excluded from the study if their injuries or physiologic condition prevented placement in the left lateral decubitus position or if the PAC had been placed more than 24 hours prior to screening. An additional exclusion criterion was the inability to place the transducer on the chest wall. The Institutional Review Board

BEAT Examination/Cardiac Index

The Bedside Echocardiographic Assessment in Trauma and Critical Care, or BEAT exam, consists of 4 parts: assessment of BEAT, that is used to assess the beating function of the heart, the Cardiac Index; EFFUSION, which evaluates the presence or absence of a pericardial effusion; AREA, which is a subjective assessment of the contractile function of the right and left ventricles; and TANK, that is used to estimate the patients volume status (Table 1). There are three methods that may be used to estimate the SV in step 1: FS, LVOT/VTI, and Simpsons methods. The SV from each method can then be used to calculate the CI.

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Gunst et al
Table 1. Steps in the BEAT Exam Goal Beat Effusion Area Tank Cardiac function Pericardial effusion R and L ventricle Volume status View Parasternal long Parasternal long Parasternal short apical 4 chamber M mode subcostal Task

257

Stroke volume Subjective assessment Subjective assessment IVC measurement

Abbreviation: IVC: inferior vena cava.

Fractional shortening: In the parasternal long-axis view, the M Mode cursor is placed across the distal mitral valve that allows a 1-dimensional cross section of the left ventricle. The left ventricular end-systolic and end-diastolic diameters are measured. The ultrasound software package then calculates the left ventricular SV (Figure 1). Left ventricular outflow tract/velocity-time integral: In the parasternal long-axis view, the diameter of the LVOT is measured and recorded. In the apical 5-chamber view, Pulsed Wave Doppler is used to measure the VTI across the LVOT. The ultrasound software package then calculates the left ventricular SV as the product of LVOT area (Figure 2) and VTI (Figure 3). Simpsons Method: In the apical 4-chamber view, a manual tracing of the left ventricular end-systolic and end-diastolic area is made. The ultrasound software package then divides the length of the left ventricle into multiple cylinders of different diameter but equal thickness. Estimates of the left ventricular end-systolic and end-diastolic volumes are used to calculate the SV (Figure 4).

Figure 1. Fractional shortening.

Statistical Analysis
Stroke volume was measured using each method (FS, VTI, and Simpsons) and was used to calculate estimates of CI. All CI estimates were categorized as low, normal, or high based on a normal range of 2.4 to 4.0 L/min per m2. The CI estimates from each of the 3 methods were compared to PAC-derived CI. Only those echocardiographic examinations that were obtainable were included in the analysis. Chi-square goodness-of-fit analysis was used to determine the association between each of the individual categorized CI and those from the PAC. Pearson correlation efficient was used to determine the relationship between the SV estimates as continuous variables. Finally, agreement between the CI from each method and the PAC was ascertained by evaluating the mean difference using the paired t test. Microsoft Excel (Redmond, Washington) was used for all data entry. Statistical software SAS (Cary, North Carolina) was used for creation of all new variables, all calculated variables, and all statistical analyses. Statistical significance was defined at P < .05.

RV LV Ao

LA

Figure 2. Left ventricular outflow tract. LA indicates left atrium; LV, left ventricle; RV, right ventricle; Ao, aorta

Results
Overall, there were 85 BEAT exams performed on 22 consecutive SICU patients with a PAC in place. The patients median age was 56 years and 47% were male. Fifty-six percent of the exams were performed on trauma patients, while 44% were performed on

general surgical patients. Patient characteristics are shown in Table 2. Mean arterial pressure, heart rate and rhythm, hemoglobin level, and PAC data are summarized in Table 3. Of the 85 BEAT exams performed, 59% of the FS images were of sufficient quality to allow measurement of the SV. The Pearson correlation coefficient for the SV estimate was 0.72 (95% CI 0.56-0.82). When the categorized FS cardiac

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258

Journal of Intensive Care Medicine 26(4)

RV RA

LV

LA

A
Figure 3. Velocity-time integral.

indices were compared to those from the PAC, there was a statistically significant association between the 2 (P .012). Furthermore, the mean difference in CI was not statistically significant between the FS and PAC (0.25, 95% CI 0.03 to 0.53). Eighty-seven percent of the LVOT/VTI images were of sufficient quality to allow a determination of the SV. We found no significant association between the categorized CI obtained from the LVOT/VTI method and those from the PAC (P .33). The mean difference in CI was statistically significant between the 2 (1.36, 95% CI 0.95-1.78). Eighty-two percent of the Simpsons images were sufficient to permit the calculation of SV and CI. There was no significant association between the categorized CI obtained from Simpsons method and those from the PAC (P .74). The mean difference in CI was statistically significant between the 2 (1.08, 95% CI 0.56-1.61). Finally, the correlation coefficients for the PAC and LVOT/VTI and Simpsons methods were poor and not statistically significant.

RV RA LA

LV

B
Figure 4. Simpsons method. (A) diastolic phase and (B) systolic phase. LA indicates left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
Median [Inter-quartile Range]

Discussion
This study demonstrates that FS, performed by intensivists in the ICU, provides a more accurate estimate of CI than the LVOT/VTI or Simpsons methods when PAC values are used as a gold standard. Estimates of CI based upon measurements of FS require only a single view during bedside echocardiographic evaluation (BEAT) and when of sufficient quality may obviate the need for a PAC. Bedside ECHO should utilize measurements of FS to estimate SV and CI in the SICU setting. In 59% of the patients, the FS images obtained allowed a determination of the SV and ultimately the CI. While in 41% of patients the estimation could not be made, failure to obtain an FS estimate of SV typically was not due to image quality. In fact, the image quality was usually good. Inability to obtain the measurement was usually the result of the orientation of the heart. In many of these patients, the heart seemed to be oriented in a more vertical plane, preventing ideal positioning of the

M Mode cursor at the distal end of the mitral valve. Fractional shortening requires a single view that usually provided a highquality image, and in this 60% of the patient cohort, placement of a PAC may have been avoided. Furthermore, although not an endpoint in our study, a qualitative assessment of global cardiac function could frequently be made despite the inability to obtain a quantitative estimate of CI. Over 80% of the images from LVOT/VTI and Simpsons methods were obtainable, but the SV estimate was inaccurate, and in contrast to FS, the image quality was usually poor. Our acquisition rate of the FS images is consistent with others reported in the literature. Jensen and colleagues16 reported a 69% useable window acquisition rate in 233 ECHO exams with the left parasternal transducer position, the view required for FS. Although the success rate in the Focused Assessed Transthoracic Echocardiography (FATE) exam was roughly 10% higher than in our study, image acquisition was

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Gunst et al
Table 2. Patient Characteristicsa Age Male BMI Trauma General surgery Mechanical ventilation Septic shock Pressor requirement Inotrope requirement
Abbreviation: BMI: body mass index. a Median [inter-quartile range].

259
Table 3. Hemodynamic Characteristicsa 56 [50, 72] 47% 26 [23, 30] 56% 44% 84% 29% 47% 13% Heart rate Mean arterial pressure Hemoglobin Sinus rhythm Sinus tachycardia Atrial fibrillation Cardiac index Central venous pressure Pulmonary artery occlusion pressure
a

103 [92, 115] 74 [66, 85] 10 [9, 11] 52% 43% 5% 3.5 [2.9, 4.5] 13 [9, 17] 17 [15, 21]

Median [inter-quartile range].

based on a qualitative assessment of cardiac function and was not dependent on proper placement of the M Mode cursor to define a useable window. Furthermore, because FATE was based solely on a subjective assessment of global cardiac function, it may not lend itself to goal-directed therapy as easily as an objective measure. Measurement and calculation of SV using each of the 3 methods relies on several assumptions with respect to the geometry of the left ventricle, the physiology of contraction, and flow dynamics to translate 1 or 2 dimensions into a 3-dimensional structure.8 As FS measures the systolic function of only the basal portion of the LV, any wall motion abnormalities may render the SV estimate inaccurate.17-19 As the majority of patients in our SICU were relatively young and suffered severe traumatic injuries, it seems less likely that other comorbid conditions (such as coronary artery disease or ventricular aneurysms) would have a major effect on regional or global contractile function. Because of the multiple components involved in the LVOT/VTI calculation, the SV estimate would ideally be based on several measurements.20 We produced an SV estimate based on a single value, as the time constraints for multiple measurements would be prohibitive in a critically ill patient and not feasible for a rapid evaluation using bedside ECHO. Perhaps the accuracy of our estimates would have improved had we performed several readings. Furthermore, as many of the patients were obese, suffered severe chest trauma, or had received a large fluid resuscitation, it was often difficult to ideally position the Doppler probe at the annulus of the aortic valve and the angle of interrogation may have been outside the 20 degree margin of error that is suggested.20,21 Simpsons method, on the other hand, requires fewer assumptions about the geometry of the left ventricle (although it does require some) and minimizes the effect of geometric shape for calculating volumes.21-23 Although we had little difficulty acquiring the apical 4-chamber view, the endocardial edge was ill-defined in the majority of our images. Many of our patients were fluid resuscitated and tachycardic, and as the apical 4-chamber view is obtained in real time, the manual tracing of the perimeter requires a still image during the dynamic process of contraction. Freezing the image obliterated a defined endocardial border and rendered the subsequent endocardial tracing inaccurate. Ultimately, whether the

superiority of Fs over LVOT/VTI and Simpsons calculation was due to patient or operator factors in this study is unclear. This study has some potential limitations in addition to those mentioned. First, the echocardiographic examinations were conducted by 6 investigators on a small group of SICU patients. Therefore, the universal efficacy of SV and CI estimates using focused ECHO has not yet been determined. Furthermore, we did not measure inter- or intra-rater variability. As treatment of shock was instituted and often changing throughout the study, calculating the inter- or intra-rater variability was not feasible as this would require several repeated examinations in patients with stable hemodynamics. We utilized a cardiologist to verify our ability to obtain appropriate images, rather than to confirm our measurements and calculations. As we used PAC-derived data as our gold standard, we felt it was unnecessary for our measurements and calculations to be repeated by the cardiologist. These PAC data, however, may not provide an accurate assessment of left ventricular SV. Further, as we subjectively determined which of the FS images were adequate for the calculations, we may have inadvertently introduced a selection bias into the comparison. Finally, the clinical utility (in terms of improved outcome) of using any modality to determine a quantitative assessment of SV and CI can certainly be questioned. Nonetheless, in institutions using algorithmic resuscitation strategies such as ours, a discrete value for SV and CI can drive consistent care.

Conclusion
Focused bedside ECHO is becoming a valuable tool in the evaluation and treatment of critically ill patients. The SV and CI estimates generated using the FS method are more accurate than those using either LVOT/VTI or Simpsons method when performed by intensivists in the SICU. As the appropriate therapy in our population of critically ill and injured patients often requires only an estimation of global cardiac function, a subjective assessment using focused ECHO may be a sufficient guide. However, if an objective measure is preferred during a bedside echocardiographic evaluation, FS provides the most accurate estimate of CI in SICU patients who are largely devoid of significant cardiac comorbidities. Whether acquisition and use of these objective values improve care and/or is generalizable to other ICU populations are subjects of further study.

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260 Authors Note

This work was presented at the 37th Critical Care Congress of the Society of Critical Care Medicine 2008. Training in focused ECHO (travel and stipend for instructor) was funded by SonoSite, Inc Bothell, WA. 10. 11.

Journal of Intensive Care Medicine 26(4)

volume and cardiac output in patients without heart disease. Chest. 1982;81(5):614-619. Feigenbaum H. Echocardiography. 6th ed. Philadelphia, PA: Lea & Febiger; 2004. de Waal E, Kalkman C, Rex S, Buhre W. Validation of a new arterial pulse contour-based cardiac output device. Crit Care Med. 2007;35(8):1904-1909. Mayer J, Boldt J, Wolf MW, Lang J, Suttner S. Cardiac output derived from arterial pressure waveform analysis in patients undergoing cardiac surgery: validity of a second generation device. Anesth Analg. 2008;106(3):867-872. Mayer J, Boldt J, Scho llhorn T, Ro hm KD, Mengistu AM, Suttner S. Semi-invasive monitoring of cardiac output by a device using arterial pressure waveform analysis: a comparison with intermittent pulmonary artery thermodilution in patients undergoing cardiac surgery. Br J Anaesth. 2007; 98(2):176-182. Biais M, Nouette-Gaulain K, Cottenceau V, et al. Cardiac output measurements in patients undergoing liver transplantation: pulmonary artery catheter versus uncalibrated arterial pressure waveform analysis. Anesth Analg. 2008;105(5):1480-1486. Gardner R, Beale R. Pressure to perform: Is cardiac output estimation from arterial waveforms good enough for routine use? Crit Care Med. 2009;37(1):337-338. Jensen M, Sloth E, Larsen K, Schmidt M. Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesth. 2004;21(9):700-707. Feigenbaum H. Echocardiographic examination of the left ventricle. Circulation. 1975;51:1-7. Chambers J. Echocardiography in Clinical Practice. New York: Informa Health Care; 2002. Willerson JT, Cohn JN, Wellens HJ, Holmes DR. Cardiovascular Medicine. 3rd ed. London: Springer-Verlag; 2007. Loonyenga DS, Liebson PR, Liebson PR, Bone RC, Balk RA. Determination of cardiac output in critically ill patients by dual beam Doppler echocardiography. J Am Coll Cardiol. 1989; 13(2):340-347. Fuster V, Alexander RW, ORourke RA. Hursts The Heart. 11th ed. New York: Mcgraw-Hill; 2004. Oh JK, Seward JB, Tajik AJ. The Echo Manual. 3rd ed. Philadelphia, PA: Lippincott-Raven; 2006. Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echo. 1989;2(5):358-367.

Acknowledgment
The authors would like to acknowledge Dr. Yanick Beaulieu, cardiologist and intensivist, who provided the training and mentorship that allowed us to complete this study. 12.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article. 13.

Funding
The author(s) received no financial support for the research and/or authorship of this article.

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