Lung and Pleural Ultrasonography Ultrasound Guided Vascular Access Goal Directed Echocardiography Measures of Volume Responsiveness

1. Lung and Pleural Ultrasonography Ultrasound Guided Vascular AccessGoal-Directed EchocardiographyMeasures of Volume Responsiveness Fellows Introductory Lecture Bassel Ericsoussi, MD Pulmonary and Critical Care Fellow University of Illinois Medical Center at Chicago 1 Bassel Ericsoussi, MD

2. “It is crucial that chest physicians take the lead in advocating for ultrasound to become part of our daily practice, create educational opportunities for members of our societies, and incorporate ultrasound training in our fellowship programs.” Dr. David Feller-Kopman Bassel Ericsoussi, MD 2

4. Hyperechoic (bright echo)

5. Air

6. Diaphragm

7. Periostium

8. Isoechoic/echogenic

9. Liver

10. Kidney

11. Muscle

12. Hypoechoic (dark echo)

13. Fluid

14. Blood

15. FatBassel Ericsoussi, MD 3

16. Bassel Ericsoussi, MD 4

17. Modes B-Mode Traditional real-time, cross-sectional scanning mode M-Mode One dimensional display of motion Bassel Ericsoussi, MD 5

18. Image Artifacts Acoustic enhancement Increase amplitude caused by intervening structures with low attenuation Acoustic shadowing Reduced amplitude caused by intervening structures with high attenuation Bassel Ericsoussi, MD 6

19. Artifacts cont. A lines “Reverberation” artifacts Horizontal lines parallel to the pleural line Distance between A-lines is equal to, or a multiple of, the distance between the skin to the pleural line Seen in normal parenchyma A lines w/o lung sliding Search for PTX Bassel Ericsoussi, MD 7

20. Bassel Ericsoussi, MD 8

22. Move with lung sliding

23. Efface A lines at their point of intersection

24. Normally seen in the lower lateral lung zones (3-4 lines)

25. lower lung zone interstitial markings are normal

26. Hence, a few Comet Tails in this area are also normal

27. Correlate with the alveolar interstitial pattern (correlate with the presence of extravascular lung water )on CXR or chest/CT

28. 7 mm apart B lines: intra-lobular septa process

29. Diffuse interstitial fibrosis

30. < 3mm apart “closely spaced” B lines: intra-alveolar process

31. Pulmonary edema (smooth pleura) or ARDS (rough pleura)Bassel Ericsoussi, MD 9

32. Bassel Ericsoussi, MD 10

34. Each reflection of the beam is displayed on the screen behindthe previous reflection.

35. A distance of about 1 mm separates eachreflection. 11 Bassel Ericsoussi, MD

36. Normal Lung few Comet Tails in the lower lung zone Acute pulmonary edema closely spaced comet-tail artifacts Diffuse interstitial fibrosis comet-tail artifacts are 7 mm apart Bassel Ericsoussi, MD 12

37. Artifacts cont. E-lines Similar to B lines but Arise from the chest wall, not from the pleural line Vertical laser-like lines that reach the edge of the screen Generated by subcutaneous emphysema Bassel Ericsoussi, MD 13

38. Artifact cont. Z line artifacts Similar to B lines arise from the pleural line Fade away vertically, do not reach the edge of the screen Do not erase the A-lines Do not accompany the lung sliding Does not have a pathologic meaning Lichtenstein et al. The comet tail artifact: an ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997;156,1640-1646 Bassel Ericsoussi, MD 14

39. Artifacts cont. Mirror image Results from the beam encountering a bright reflector (diaphragm) Produces a false object, deep to the mirror that disappears with subtle changes in transducer position Bassel Ericsoussi, MD 15

40. Probes Cardiac Abdominal Endocavity Vascular Lungs 2.5-3.5 MHz 3.5-5.0 MHz 5.0-7.5 MHz 7.5-10 MHz 5 mhz curvilinear probe is ideal (low frequency for deeper tissue) Bassel Ericsoussi, MD 16

41. 7.5-10 MHz Superficial structures (vessels) 1.0-5.0 MHz Cardiac Lung Abdomen Bassel Ericsoussi, MD 17

42. Penetration vs. Resolution Higher frequency, less penetration but better resolution Good for vessels “vascular/linear probe” 7.5 Mhz Lower frequency, better penetration but less resolution Good for abdomen, heart, lung “ genera probe” 3.5 Mhz Bassel Ericsoussi, MD 18

43. Knobology Patient ID Mode Depth Gain THI Save Annotations Bassel Ericsoussi, MD 19

44. Lung Ultrasonography Compared to Chest Radiography Lung ultrasonography is superior to supine portable chest radiographs for detection of PTX Normal aeration pattern Alveolar-interstitial pattern Consolidation Pleural effusion Bassel Ericsoussi, MD 20

45. Equipment Requirement 3.5-5.0 MHz transducer Cardiac probe is very effective Has small footprint to fit into narrow intercostal space Bassel Ericsoussi, MD 21

46. Technique Pt supine with arms abducted as needed, lateral decubitus for full examination Transducer in longitudinal orientation Transducer in intercostal space Transducer marker in cephalic position Bassel Ericsoussi, MD 22

47. Ultrasonographic Findings in Normal Lung Sliding lung Lung pulse Pleural Line A lines B lines/Comet-tails Bassel Ericsoussi, MD 23

48. Sliding Lung Sign Represents the movement of visceral against parietal pleura during the respiratory cycle Identified as a shimmering white line at the pleural interface http://www.sonoguide.com/FAST_Video7.html (Shows normal “lung sliding” in its first part. The second part of the clip shows an abnormal chest view without lung sliding, suspicious for a pneumothorax) Bassel Ericsoussi, MD 24

50. Its visible length between two ribs in the longitudinal scan is approximately 2 cm

51. The upper rib, pleural line, and lower rib (vertical arrows) outline a characteristic pattern called the bat signBassel Ericsoussi, MD 25

52. A Lines “Reverberation” artifacts Horizontal lines parallel to the pleural line. Separated by regular intervals that are equal to the distance between the skin and the pleural line. Seen in normal aeration pattern Predominant A lines plus lung sliding Asthma or COPD Predominant A lines plus absent lung sliding PTX Bassel Ericsoussi, MD 26

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54. Bassel Ericsoussi, MD 28

56. Move with lung sliding

57. Efface A lines at their point of intersection

58. Normally seen in the lower lateral lung zones (3-4 lines)

59. lower lung zone interstitial markings are normal.

60. Hence, a few Comet Tails in this area are also normal

61. Correlate with the alveolar interstitial pattern (correlate with the presence of extravascular lung water )on CXR or chest/CT

62. 7 mm apart B lines: intra-lobular septa process

63. Diffuse interstitial fibrosis

64. < 3mm apart “closely spaced” B lines: intra-alveolar process

65. Pulmonary edema (smooth pleura) or ARDS (rough pleura)Bassel Ericsoussi, MD 29

66. Normal Lung few Comet Tails in the lower lung zone Acute pulmonary edema closely spaced comet-tail artifacts Diffuse interstitial fibrosis comet-tail artifacts are 7 mm apart Bassel Ericsoussi, MD 30

67. E-lines Generated by subcutaneous emphysema Vertical laser-like lines that reach the edge of the screen Similar to B lines but Arise from the chest wall, not from the pleural line Bassel Ericsoussi, MD 31

68. Using Ultrasound to Evaluate for a Pneumothorax Probe placement On the anterior chest in the 3-4th intercostal space and midclavicular line Air rises to the anterior chest wall It is possible to examine the anterior chest very rapidly to promptly exclude PTX In a longitudinal position with the marker-dot pointed cephalad Bassel Ericsoussi, MD 32

69. Bassel Ericsoussi, MD 33

70. Using Ultrasound to Evaluate for a Pneumothorax A high frequency vascular probe but a curvilinear abdominal probe will also work well Decrease the depth setting, so that the ultrasound image shows a maximum depth of about 4 cm. Bassel Ericsoussi, MD 34

71. Using Ultrasound to Evaluate for a Pneumothorax http://www.sonoguide.com/FAST_Video7.html (Shows normal “lung sliding” in its first part. The second part of the clip shows an abnormal chest view without lung sliding, suspicious for a pneumothorax) Bassel Ericsoussi, MD 35

72. Using Ultrasound to Evaluate for a Pneumothorax The presence of sliding lung rules out PTX with 100% certainty at the site of the transducer However the lack of sliding lung indicates the possibility of PTX PTX Apnea Pleural adhesions Mainstem intubation Mainstem occlusion Very severe parenchymal lung (infiltrates/contusion/ARDS/Atelectasis) Bassel Ericsoussi, MD 36

74. M-mode: Seashore Sign

75. Horizontal lines (“waves”) representing the static chest wall

76. granular pattern (“sand”) representing the dynamic artifacts beyond the pleural lineBassel Ericsoussi, MD 37

77. Bassel Ericsoussi, MD 38

78. SEASHORE SIGN Bassel Ericsoussi, MD 39

79. Using Ultrasound to Evaluate for a PneumothoraxB-mode vs. M-modePTX B-mode: Lack of sliding lung M-mode: Stratosphere or Barcode Sign The granular pattern disappear. The seashore sign turn to barcode sign Bassel Ericsoussi, MD 40

80. Bassel Ericsoussi, MD 41

81. STRATOSPHERE SIGN Bassel Ericsoussi, MD 42

82. Using Ultrasound to Evaluate for a PneumothoraxB-mode vs. M-modeLung Point M-mode: Lung Point Sign appear at the precise line where the seashore sign switch to Stratosphere /barcode sign It is a very specific sign for PTX Bassel Ericsoussi, MD 43

83. Using Ultrasound to Evaluate for a Pneumothorax Identifying the lung point is 100% diagnostic for PTX Found at the area where the lung reaches the chest wall http://www.sonoguide.com/FAST_Video8.html (Visceral and parietal pleural movement shows the lung point of a pneumothorax) Bassel Ericsoussi, MD 44

84. Using Ultrasound to Evaluate for a Pneumothorax Identifying the lung point is 100% diagnostic for PTX Absence of lung sliding on B-mode, or stratosphere/barcode sign on M-mode (indicates the possibility of PTX) PTX Apnea Pleural adhesions Mainstem intubation Mainstem occlusion Very severe parenchymal lung (infiltrates/contusion/ARDS/Atelectasis) A-lines with no B-lines/comet-tails is suggestive of PTX Bassel Ericsoussi, MD 45

85. Using Ultrasound to Evaluate for a Pneumothorax American Academy of Emergency Medicine : Chan SSW et al Acad Emerg Med Jan 2003 Vol.10 1. Bassel Ericsoussi, MD 46

86. Using Ultrasound to Evaluate for a Pneumothorax http://www.youtube.com/watch?v=fntJ7GLjCSU&feature=PlayList&p=B9E542E5A7E42CD3 Bassel Ericsoussi, MD 47

87. Ultrasound Guided Vascular Access Why not identify the target vessel with ultrasonography, instead of using landmark Bassel Ericsoussi, MD 48

88. General Reference Bassel Ericsoussi, MD 49

89. Common Arguments Against US Guidance I don’t need it It complicates my set-up routine I will lose skill at land mark technique My house officers won’t develop landmark skills I will become dependent on a machine Bassel Ericsoussi, MD 50

90. The Evidence US guidance increases success rate and reduces complication rate Time saving Comfort of the patient Reduction in infection Standard of care Bassel Ericsoussi, MD 51

91. Anatomic Variation in IJ Significant anatomic variation in IJ position and size is common Real time US-guidance for vascular access should be applied all the time Bassel Ericsoussi, MD 52

92. Bassel Ericsoussi, MD 53

94. Good for vessels “vascular/linear probe” 7.5 Mhz

95. Color doppler is desirable but not requiredBassel Ericsoussi, MD 54 7.5-10 MHz Superficial structures (vessels)

96. Some Suggestions Always use a sterile transducer cover Chlorhexidine is an excellent US coupling medium Position the screen so that it is easily visible to the operator without head turning Bassel Ericsoussi, MD 55

97. Real Time vs. Marking Why use anything but real-time guidance? Real-time guidance is superior to “mark and stick” technique Bassel Ericsoussi, MD 56

99. Check sliding lung for later comparison post insertion

100. Prepare the pt as per routine with sterile transducer cover and properly positioned machine

101. Obtain transverse view of the IJ

102. Examine the entire vessel: size, visible clot, stenosis, compressibilityBassel Ericsoussi, MD 57

104. Hold transducer perpendicular in transverse section

105. Vessel localized to exact center of the transducer

106. Needle insertion 0.5-1.0 cm from transducer at appropriate angle

107. Advance needle watching for tissue movement, needle identification and vessel compression by the needleBassel Ericsoussi, MD 58

108. Problems Avoid site of insertion that places the carotid deep to IJ Avoid pressure that will collapse vessel Needle tip may be difficult to visualize Bassel Ericsoussi, MD 59

109. Transverse view: The IJ vein anterior and lateral to the carotid artery Significant overlap of the artery Transverse view: Less contralateral head rotation less overlap of the artery Longitudinal view of the IJ vein Bassel Ericsoussi, MD 60

110. For the Safety Conscious Visualize the wire in longitudinal view before dilatation Check for sliding lung post-procedure in order to rule out PTX Bassel Ericsoussi, MD 61

112. Go lateral and stay away from the clavicle

113. Locate sc vein in transverse plane

114. Rotate the transducer to longitudinal view of the vein

115. Advance needle along midline long axis of the transducer

116. Do not proceed unless the needle is clearly in US imaging plane!Bassel Ericsoussi, MD 62

117. Bassel Ericsoussi, MD 63

118. Bassel Ericsoussi, MD 64

119. Ultrasound Guided Central Venous Catheter Placement Bassel Ericsoussi, MD 65 http://www.youtube.com/watch?v=Ahz1SPKTiBU

120. Placement of an Arterial Line The placement of arterial lines is an important skill for physicians to master as they treat critically ill patients Bassel Ericsoussi, MD 66

122. Placement of an Arterial LineIndications Patients with hemodynamic instability Patients on vasoactive medications Patients undergoing/recovering from major surgery Patients requiring frequent ABG’s Continuous monitoring of blood pressure allows for better assessment and management of the critically ill patient Bassel Ericsoussi, MD 68

123. Placement of an Arterial Line Contraindications Coagulopathy Infection of the insertion site Scar tissue in the insertion site Trauma proximal to the insertion site Poor collateral circulation Advanced atherosclerosis Raynaud’s phenomenon Thromboangiitis obliterans Bassel Ericsoussi, MD 69

124. Placement of an Arterial Line Selecting the Site Bassel Ericsoussi, MD 70

126. It may give some qualitative assessment of collateral perfusion

127. Allen Test

128. Apply pressure on both the ulnar and radial arteries, while the patient tightly making a fist

129. The hand then is opened

130. Release pressure from one of the arteries

131. Circulation should return to the extremity within 5 sec

132. Any delay suggests poor collateral circulationBassel Ericsoussi, MD 71

134. Sterile prep and field

135. Needle, catheter and wire

136. 1 % Lidocaine (without epinephrine) with 12 gauge needle and syringe

137. Scalpel or large bore needle

138. Suture and needle drive

139. Wrist board or roll

140. Transduction system for monitoringBassel Ericsoussi, MD 72

142. Over the wire technique

143. Over the needle technique

144. Modified Seldinger technique

145. Hand Positioning

146. Hand should be positioned on the wrist board

147. Moderate dorsiflexion, roll placed under the wrist (brings the artery closer to the skin)Bassel Ericsoussi, MD 73

148. Placement of an Arterial Line The radial artery Palpated 1 to 2 cm from the wrist Between the bony head of the distal radius and the Flexor Carpi Radialis Tendon Bassel Ericsoussi, MD 74

150. Once a flash of blood is seen in the hub of the catheter

151. Advance the catheter slowly

152. Pull the needle slowly

153. Until pulsatile blood flow is observed

154. Advanced the wire into the vessel

155. Remove the needle

156. Advance the catheter over the wire

157. Remove the wire (Apply pressure over the artery proximal to the catheter before removing the wire)

158. Connect the catheter to a transduction systemBassel Ericsoussi, MD 75

159. Over-the-needle Technique The initial approach is the same Once pulsatile blood return is seen in the catheter Lower The catheter angle should then be lowered toe catheter angle to 10-15 degree Advance the catheter over the needle into the vessel Bassel Ericsoussi, MD 76

161. Suturing (the preferred method)

162. Taping

163. Assessment of hand perfusion

164. Before and after placement of the arterial line

165. Frequent intervals while the line is in use

166. check color, temp, capillary refill, and sensation in the hand.

167. Removal of the arterial line

168. Any sign of vascular compromise

169. it is no longer neededBassel Ericsoussi, MD 77

171. Unable to advance the catheter , catheter hung up on the skin

172. Make a skin nick using larger bore needle

173. No blood return is obtained after the initial flush of blood

174. Advance the catheter through the vessel

175. Then switch to over the wire technique

176. Free flow of blood is observed but the catheter will not pass easily

177. Advance the needle slightly farther, the catheter can enter the arteryBassel Ericsoussi, MD 78

178. Placement of an Arterial LineArtery Spasm Due to multiple attempts of cannulation Nearly impossible to cannulate A new site should be chosen Bassel Ericsoussi, MD 79

179. Placement of an Arterial LineTips and Pointers If the catheter is in the radial artery, don’t hyperextend the wrist…it can cause nerve damage Don’t deliver meds via an arterial line Keep pressure bag at 300 mm Hg to maintain a continuous flow of 2-3 ml/hr of flush solution Bassel Ericsoussi, MD 80

181. Hemorrhage

182. Can lose blood at a rate of 500 ml/min with disconnection

183. Hidden bleeding can occur if the catheter tip punctures the posterior wall of the artery

184. Thrombus

185. Embolism (air or thrombus)

186. Decreased distal blood flow

187. Nerve damageBassel Ericsoussi, MD 81

188. Placement of an Arterial Line The Waveforms Bassel Ericsoussi, MD 82

189. Placement of an Arterial Line The Normal Waveform Bassel Ericsoussi, MD 83 Dicrotic limb Aanacrotic limb rapid ejection of blood from the ventricle Aortic valve closes causing some retrograde blood flow. Opening of the aortic Valve SQUARE WAVE TEST: 1.5-2 oscillations before returning to baseline

191. Too many stopcocks

192. Kink in the catheter

193. kink in the tubing

194. Blood on the transducer

195. Clot in the catheter

196. Empty flush bag

197. Aortic stenosis

198. Vasodilation

200. Smooth waveform that loses the dicrotic notch

201. SBP falsely low

202. DBP may be high

204. Excessive catheter movement

205. Atherosclerosis

206. Vasoconstriction

207. Aortic regurgitation

208. Hyperdynamic states

210. Sharp exaggerated waveform with overshoot of the systolic pressure and undershoot of the diastolic

212. PulsusParadoxus: amplitude decreases during inspiration and increases during expiration

213. Irregular rhythm

215. Goal Directed Echocardiography in Shock Using a goal-directed echocardiographic approach combined with clinical context, you can reliably diagnose causes of shock Easy to learn Rapid to perform Changes management 60-70% of time in ICU (DEBATED) Bassel Ericsoussi, MD 88

216. Goal Directed Echocardiography Training 80% sensitivity for “clinically important findings” IM residents 20 hr course 20 goal directed studies Bassel Ericsoussi, MD 89

217. Bassel Ericsoussi, MD 90

218. Bassel Ericsoussi, MD 91

219. Parasternal Long Axis View Probe position Left of the sternum 3rd-4th intercostal space Marker toward the pt’s right shoulder Bassel Ericsoussi, MD 92

220. Parasternal Long Axis View Bassel Ericsoussi, MD 93

221. Parasternal Long Axis View Bassel Ericsoussi, MD 94

222. Parasternal Short Axis View Probe position Rotate the probe 90 degree from the PSLA view The marker toward the pt’s left shoulder 3 views (tilting the probe toward the base or toward the apex) At the level of mitral valve At the level of papillary muscles At the level of the aortic valve Bassel Ericsoussi, MD 95

223. Parasternal Short Axis View Bassel Ericsoussi, MD 96

224. Parasternal Short Axis ViewAt the Level of the Mitral Valve Bassel Ericsoussi, MD 97

225. Parasternal Short Axis ViewAt the Level of the Papillary Muscles Bassel Ericsoussi, MD 98

226. Parasternal Short Axis ViewAt the level of aortic valve Bassel Ericsoussi, MD 99

227. Apical 4 Chambers View Probe position Point of Maximal Impulse (PMI) The probe’s marker toward the pt’s left posterior axillae Bassel Ericsoussi, MD 100

228. Apical 4 Chambers View Bassel Ericsoussi, MD 101

229. Apical 4 Chambers View Bassel Ericsoussi, MD 102

230. Subcostal View The easiest to be obtained in an ICU pt Probe location Subcostal area Marker toward the pt’s left side Acute angle toward the pt’s left shoulder Bassel Ericsoussi, MD 103

231. Subcostal View Bassel Ericsoussi, MD 104

232. Subcostal View Bassel Ericsoussi, MD 105

234. Severe ventricular failure

235. Severe LV dysfunction (EF<25%)

236. Decreased LV contractility

237. Severe LV hypokinesis

238. Wall motion abnormality

239. Cardiorespiratory arrest

240. During CPR in a pulseless pt

241. Lack of mechanical cardiac activity: very poor prognosis Bassel Ericsoussi, MD 106

242. Goal Directed Echocardiography in Shock Hypovolemic Shock Severe underfilling of LV Small and hyperdynamic LV Systolic obliteration of LV cavity Small IVC with respiratory variability Bassel Ericsoussi, MD 107

244. PE

245. ARDS (High PEEP, increased pulmonary vascular resistance)

246. RV infarct

247. Air/fat embolism

248. Severe RV Dilation: RV size > LV size (normal RV size = 60% of LV)

249. Severe RV dysfunction

250. Apex formed by RV

251. Paradoxical septal movement

252. RA dilation

253. Dilated and invariable IVC

254. Small and Hyperdynamic LVBassel Ericsoussi, MD 108

256. EchoJournal: Echocardiography Videos and Discussions - RV pressure overload causes D sign

257. McConnell’s Sign: Regional wall motion abnormalities that spare the right ventricular apex

258. http://www.echojournal.org/video/132/McConnells-Sign-RV-dysfunction-in-pulmonary-embolus

259. RV dilation (RV > LV), apex formed by RV, Tricuspid regurgitation (RV failure in acute pulmonary embolus )

260. http://www.echojournal.org/video/133/Huge-Tricuspid-Regurg-Jet

261. http://www.echojournal.org/video/79/Classic-appearance-of-RV-failure-in-acute-pulmonary-embolus-1-of-2

262. http://www.echojournal.org/video/80/Classic-appearance-of-RV-failure-in-acute-pulmonary-embolus-2-of-2Bassel Ericsoussi, MD Pulmonary and Critical Care Fellow

269. Goal Directed Echocardiography in Shock Tamponade Pericardial effusion (PSLA view is best for differentiating pleural from pericardial effusion) Diastolic collapse of RV and RA IVC Dilated without respiratory variation Bassel Ericsoussi, MD 116

270. Diastolic Collapse of RV Bassel Ericsoussi, MD 117

271. Assessment of Fluid Status and Measures of Volume Responsiveness When to do volume challenge and volume rescusetation? Pulse pressure variation (needs arterial line) Bassel Ericsoussi, MD 118

272. Assessment of Fluid Status and Measures of Volume Responsiveness IVC variation In subcostal view measure IVC 3 cm from RA Max D – min D / average D > 12% Max D - min D / min D > 18% Bassel Ericsoussi, MD 119

273. Assessment of Fluid Status and Measures of Volume Responsiveness Limitations of IVC and pulse pressure variations, all patients must be Sinus rhythm Passive on ventilator (AC) Off pressors Absence of increased abdominal pressure Good luck finding these patient Bassel Ericsoussi, MD 120

275. Subcostal

276. Longitudinal

277. The probe’s marker toward the pt’s feet

278. Measure proximal IVC AP diameter 3 cm from the RA

279. With sniffing or forceful inhalation

280. Collapses > 50 %: normal

281. Collapses < 50 %: elevated CVP and right sided pressuresBassel Ericsoussi, MD 121

282. IVC Evaluation Bassel Ericsoussi, MD 122

283. IVC Evaluation Bassel Ericsoussi, MD 123

284. > 50 % collapse with inhalation: normal Bassel Ericsoussi, MD 124

285. < 50 % collapse with inhalation:elevated CVP and right sided pressures Bassel Ericsoussi, MD 125

287. Sinus or irregular rhythm

288. Spontaneous breathing or on ventilator

289. On pressors or off pressors

290. Use apical 5 chamber view and measure the aortic blood flow (stroke volume)

291. Raise legs to 45 degree (you have just given a “blood bolus” 500 ml blood in legs returned to the heart)

292. Wait 30-60-90 sec (highest values within 90 sec)

293. Recheck the stroke volume

294. SVV > 12%Bassel Ericsoussi, MD 126

295. Goal Directed Echocardiography in Shock Video Bassel Ericsoussi, MD 127