CRITICAL CARE ECHO ROUNDS: Haemodynamic instability

The use of echocardiography, whilst well established in cardiology, is a relatively new concept in critical care medicine. However, in recent years echocardiography's potential as both a diagnostic tool and a form of advanced monitoring in the critically ill patient has been increasingly recognised. In this series of Critical Care Echo Rounds, we explore the role of echocardiography in critical illness, beginning here with haemodynamic instability. We discuss the pathophysiology of the shock state, the techniques available to manage haemodynamic compromise, and the unique role which echocardiography plays in this complex process. CASE: A 69-year-old female presents to the emergency department with a fever, confusion and pain on urinating. Her blood pressure on arrival was 70/40, with heart rate of 117 bpm Despite 3 l of i.v. fluid she remained hypotensive. A central venous catheter was inserted and noradrenaline infusion commenced, and she was admitted to the intensive care unit for management of her shock state. At 6 h post admission, she was on high dose of noradrenaline (0.7 μg/kg per min) but blood pressure remained problematic. An echocardiogram was requested to better determine her haemodynamic state.