ImaCor Hemodynamic Management
In This Issue
Cardiovascular Support Algorithm Trauma/Acute Care Surgery Service
Right Ventricular Dysfunction in Sepsis
Weaning and Reducing Pressors with hTEE
Clinical Evidence that Supports the Impact of the hTEE Approach
New Zura v.2.1.5 Released!
____________________
 
 Hemodynamic Management Course
May 11-12, 2012  
  ESICM Education Course
   
We are pleased to
participate in the 2-Day ESICM Education and Training Session on Hemodynamic Monitoring and Management in Bern, Switzerland May 11-12
____________________
 
Upcoming
hTEE logo
 Courses
  hTEE Course Dates:
May 19th  Iselin, NJ
June 30th Chicago, IL

May 19 Course in Iselin NJ   
  
 Testimonial


"Using the  
ClariTEE® 
during a
prolonged
liver/colon
resection
case allowed
me to
accurately
monitor and
maintain fluid
balance. 
CVP was
often
misleading
during this
case
.

 
Selma Ishag MD
Barnes Jewish Hospital (Washington University) 
Claritee probe

 
 
Cineloop Image

To Preview Cineloops of a recent case, click here.
 
 
 Weaning Pressors Video

weaning pressors video blast
Wean Patients off Support Faster. View it now!
 
 Photo Gallery

Will Costello MD
Will Costello MD from Vanderbilt University Medical Center, right, demonstrating hTEE to two physicians
Scott Morgan Clinical Specialist
Scott Morgan, Clinical Specialist, participating in an ongoing case review at UAB Alabama at Birmingham
Erasmus physicians
Physicians in The Netherlands episodically assessing fluid responsiveness through use of the hTEE SVC view
 
Reading Room
Online image interpretation module


 
 
Contact Us
 

 

imacorinc.com 

 

 

 
 
1-516-393-0970 
 

*****

 

Should you wish to submit an article to our next monthly newsletter, 
please contact:

  

 

Sheila McGarrigle at
newsletter@imacorinc.com



topSpotlight series Cardiovascular Support Algorithm

Trauma/Acute Care Surgery Service

Wake Forest Baptist Health

by Michael C. Chang MD, Wake Forest Baptist Health

 

  

Michael Chang MD
Michael C. Chang MD

Diagnosis and subsequent appropriate support of the cardiovascular system in critically injured and critically ill surgical patients is the foundation of management in these very complex patients. The clinician's ability to provide adequate and appropriate therapy depends upon the understanding of three fundamental principles: 1) the definitions of global cardiovascular performance and tissue perfusion, 2) a working knowledge of the independent determinants of cardiovascular function and how they affect global cardiac function, and 3) a basic understanding of how the heart interacts with the pulmonary and systemic vascular systems, referred to as Ventricular-Vascular Coupling. Understanding and applying these principles is of paramount importance if the clinician expects to have the patient achieve optimal perfusion in the shortest possible time while minimizing complications. . .    

 

Independent Determinants of Cardiovascular Function

If global cardiovascular function is found to be inadequate, the next diagnostic step should involve determining which one or more of the independent determinants of cardiovascular function (heart rate, preload, afterload, or myocardial contractility) are deranged. . .

 

Once vasoactive/inotropic agents are begun, measurements of LVEDA and FAC are repeated to assess efficacy, and further titration is continued until cardiovascular performance is optimized. Of note, complex critically ill and injured patients will be quite dynamic from the standpoint of preload, contractility and afterload. For this reason, ongoing assessment with frequent interventions, including fluid administration and medication titration, will be required and is supported by the ImaCor hTEE probe.  

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Featured Clinical CaseRight Ventricular Dysfunction in Sepsis: Now You See It, Now You Don't
by James Mykytenko MD, Ricardo Levin MD, Chad E. Wagner MD, Vanderbilt University Medical Center

James Mykytenko photo
James Mykytenko MD
Current Surviving Sepsis Campaign guidelines inadequately address
the limitations of central venous pressure monitoring, which are due, in part, to right and left ventricular dysfunction associated with sepsis. Septic cardiomyopathy is well described in the literature but is both underrecognized and undertreated clinically. Direct cardiac assessment with transesophageal echocardiography (TEE) has documented advantages, but is limited by single evaluations and the need for advanced training. Recently, a disposable, monoplane TEE probe that provides for serial echocardiographic assessments in unstable patients to guide medical management, or hemodynamic TEE (hTEE), has been introduced. This article reviews a case of a 48-year-old gentleman with a history of smoking, chronic obstructive pulmonary disease, and Child's A cirrhosis who underwent an uneventful off-pump coronary artery bypass grafting and 2 days later developed septic shock from pneumonia complicated by right ventricular dysfunction. hTEE provided a rational guide to fluid resuscitation, vasopressor, and inotropic therapy with ensuing patient convalescence. Although there is a lack of hTEE experience among current intensivists, there is a desire to learn echocardiography as witnessed by the success of echocardiography courses and interest among critical care fellows. Future work to assess echocardiographic hemodynamic protocols and their effect on outcomes will be important. 
Click to Play the Cineloop - Before hTEE Intervention 
 
 Before hTEE intervention

Click to Play the Cineloop - After hTEE Intervention

After hTEE Intervention
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Literature Review tab

Weaning and reducing pressors with hTEE - A summary of cases by hTEE users  

by Harold Hastings PhD, Chief Technology Officer

(Excerpted, link to read full article with case summaries)

 

Summary
We have seen an increase in interest in weaning or reducing pressors among hTEE users; in particular, Dr. Jiri Horak from the Hospital of the University of Pennsylvania continues to regularly use hTEE for this purpose. Dr. Horak and Dr. Amy Reed (now at Beth Deaconess Medical Center, Boston) presented two recent cases at the 2012 SCCM meeting in Houston. This interest led me to take another look and review how physicians have used hTEE to wean or reduce pressors - here are some representative cases presented at meetings or published by hTEE users, together with two studies presented at meetings by hTEE users.
 
Background 
Hemodynamic instability (shock) may arise from many underlying causes: hypovolemia, systolic dysfunction, diastolic dysfunction, tamponade, sepsis, etc., and the intensivist has a large armamentarium of available therapies, including administration of fluids, inotropes and pressors. Although pressors play an important role in the management of hemodynamic instability, their use has been connected with a variety of adverse events, including acute kidney injury and pressure ulcers (Cox J. Predictors of Pressure Ulcers in Adult Critical Care Patients. American Journal of Critical Care. 2011;20:364-375) . . .                                      

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Economics Update
Clinical Evidence that Supports the Impact of the hTEE Approach

by Brandon von Tobel MD 

Vice President, Finance & Operations   

 

(Excerpted, link to full article

 

Over the past three years, ImaCor has had the wonderful opportunity to partner with some of the best clinicians at some of the best hospitals in the world. These enduring partnerships have led to the publication of clinical abstracts, case reports, and journal articles about the direct impact ImaCor's miniaturized ClariTEE™ probe has had on the care of their patients. In total, we have amassed 48 clinical publications and have approximately 10 multicenter studies at various stages of development taking place around the world  . . .  

 

Using the ClariTEE probe episodically and having it continuously available over a 72-hour time period impacts and changes management. With earlier and more effective clinical interventions, clinicians can improve patient care, reduce resource utilization, and shorten length of stay, which in turn has a beneficial economic impact on the overall hospital's bottom line.    

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New Development
New Zura v.2.1.5 Released!  

(Excerpted, link to full article

 

We are pleased to introduce our new Zura software version 2.1.5, now available to all existing and prospective customers.    

 

Version 2.1.5 smallThe Zura software offers the following new features designed to make image acquisition even easier, cleaner and faster to obtain:

  • A new Initialization Screen demonstrating hTEE views and tutorials to remind busy clinicians of the three-view hTEE exam during system start-up;
  • Access to the three-view hTEE exam directly from the Imaging Screen to reinforce ImaCor training of new users;
  • Enhanced Auto-Q, the gain control feature which automatically adjusts levels for optimal image clarity in less than one second;
  • Cineloop Image Quality Settings stores & recalls any adjustments made to cineloop image quality during playback;  
  • Simplified steering of the ultrasound image with console keys to steer left and right rather than move the probe indwelling;

Read More

 

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 .

 

As indicated by the growing body of hTEE clinical cases, the ImaCor ClariTEE® probe positively impacts patient outcomes in the critical care setting. Learning the mechanics and subsequent results of how our users integrate hTEE into their patient care processes is also extraordinarily impactful; my thanks to Michael Chang, MD of Wake Forest and James Mykytenko, MD of Vanderbilt for their valued contributions.

 

Dr. Chang wrote an introduction to the cardiovascular support algorithm developed by the Trauma/Acute Care Surgery Service at Wake Forest to assist with patients experiencing hypoperfusion and/or requiring medication titration.  Another hTEE indication focuses on RV dysfunction, which as we know from several articles (Pulido et al, 2010; Furian et al, 2011; Tongyoo et al, 2011) occurs in 18-30% of sepsis patients. Dr. Mykytenko outlined in his case, how hTEE helped him: "The information gained from direct assessment of RV function in this case changed management...and contributed to a good outcome." Our users report that another significant benefit of hTEE is the ability to guide rapid weaning from life support. To that end, our Co-Founder and Chief Technology Officer Harold Hastings PhD conducted a literature review of recent cases and identified some striking patterns of hTEE use in high-risk and moderate-risk patients.  Through hTEE, physicians are acting early and decisively to uncover the underlying causes of hemodynamic instability to get their patients off life support faster.  

 

And as our Chief Financial Officer Brandon von Tobel MD explains in his article, effective weaning off of life support enables patients to leave the ICU faster which is beneficial from a safety and an economic standpoint.  ImaCor can help fast track a patient from the ICU when dealing with pharmacologic, ventilator, and/or mechanical support. The hTEE approach helps clinicians stabilize, wean, and manage their patients better. Hemodynamic instability is expensive, and when improperly managed, costs can skyrocket. hTEE enables you to find the exact cause of the hemodynamic instability, manage patients properly and, as a result, reduce costs.

 

As Dr. Mykytenko noted in his abstract, there is strong interest in learning transesophageal echocardiography (TEE) among intensivists and fellows.  We continue to focus on training with our reading room and clinical training pathway, a five-step program which helps physicians learn the hTEE exam.  hTEE is becoming a standard of care at many of our user's hospitals and medical centers. We encourage you to join us at one of our courses on May 19 or June 30 as we prepare a new generation of hTEE users.

 

With kind regards,

 

 

Peter Pellerito

President & CEO

 

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