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Transpulmonary thermodilution devices have been widely shown to be accurate in septic shock patients in assessing fluid responsiveness. We conducted a systematic review to assess the relationship between fluid therapy protocols guided by transpulmonary thermodilution devices on fluid balance and the amount of intravenous fluid used in septic shock. We searched MEDLINE, Embase and The Cochrane Library. Studies were eligible for inclusion if they were prospective, parallel trials that were conducted in an intensive care setting in patients with septic shock. The comparator group was either central venous pressure, early goal-directed therapy or pulmonary artery occlusion pressure. Studies assessing only the accuracy of fluid responsiveness prediction by transpulmonary thermodilution devices were excluded. Two reviewers independently performed the search, extracted data and assessed the bias of each study. In total 27 full-text articles were identified for eligibility; of these, nine studies were identified for inclusion in the systematic review. Three of these trials used dynamic parameters derived from transpulmonary thermodilution devices and six used primarily static parameters to guide fluid therapy. There was evidence for a significant reduction in positive fluid balance in four out of the nine studies. From the available studies, the results suggest the benefit of transpulmonary thermodilution monitoring in the septic shock population with regard to reducing positive fluid balance is seen when the devices are utilised for at least 72 hours. Both dynamic and static parameters derived from transpulmonary thermodilution devices appear to lead to a reduction in positive fluid balance in septic shock patients compared to measurements of central venous pressure and early goal-directed therapy.

Critical care ultrasonography allows rapid bedside assessment and monitoring of severely ill patients. It provides important information on a real-time basis for patients' management and clinical decision-making, leading to improvements in delivered quality of care. Provision of this service is not possible without appropriate equipment. This document recommends minimum standards for ultrasound equipment required for use in intensive care units in Australia and New Zealand.

Critical care echocardiography (CCE) is commonly performed in many intensive care units across Australia and New Zealand (ANZ). The scope of practice ranges from Basic CCE through to Advanced CCE and includes the use of transthoracic echocardiography and transoesophageal echocardiography. Many training and qualification pathways exist with no standardisation of education goals. This document defines different levels of CCE expertise and recommends minimum training standards for each level of adult CCE in ANZ. Guidelines committee of College of Intensive Care Medicine's Ultrasound Special Interest Group held multiple face to face meetings, organised teleconferences, conducted a survey of the Fellows of the college and reviewed the international CCE training pathways prior to writing these guidelines.

OBJECTIVE: To describe the recommended procedure and common ultrasonographic findings and present a framework for labelling, recording and reporting of images obtained during a focused lung ultrasound study. BACKGROUND: Lung ultrasound is a widely utilised point‐of‐care investigation in acute care, providing valuable diagnostic information in patients with dyspnoea or haemodynamic instability. It has a number of recognised advantages and has been incorporated into a variety of clinical algorithms. Recommendations for performing lung ultrasound and description of common artefacts are readily available; however, there is a lack of a recognised framework for labelling and reporting a lung ultrasound study. Standardised recording, labelling and reporting are important clinically, while promoting consistency, quality assurance, teaching and research opportunities. Documenting lung ultrasound also has potential medico‐legal implications. RESULTS: For focused lung ultrasound, an extended bilateral four‐quadrant approach is recommended. Acquired images and loops should be clearly labelled identifying left or right, anterior or lateral and inferior, superior or posterior locations. 2D loops should be of sufficient length to clearly demonstrate pleural sliding, complemented by M‐mode stills if required. Reports should provide information regarding the presence or absence of an intact pleural interface, the presence or absence and the size and nature of pleural collections as well as any parenchymal artefacts or consolidation, in all examined locations. It is important to use internationally accepted terminology to describe findings, and it is also recommended to conclude the report with a clear summary that can be interpreted by healthcare providers without specific training in lung ultrasound.

Rheumatic heart disease is becoming far less common in the developed world, and therefore expsoure to its complications are been seen less by clinicians. With the increasing ease of world travel, patients with less commonly seen medical conditions are increasingly presenting to Hospitals requiring management of their complications. We present a case of an elderly lady who was a tourist in Australia, who presented with complications of her rheumatic heart disease, and her subsequent radiological and echocardiographic investigations were a significant surpirse for her treating clinicians.

The severe acute respiratory syndrome coronavirus 2 (COVID‐19) pandemic has placed an unprecedented challenge on healthcare systems across the globe. Rapid assessment of the cardiorespiratory function to monitor disease progression and guide treatment is essential. Therefore, we have designed the COVID‐US: a simplified cardiopulmonary ultrasound approach to use in suspected and confirmed COVID‐19 patients, to aid front‐line health workers in their decision‐making in a surge crisis.

Abnormal septal motion (commonly referred to as septal bounce) is a common echocardiographic finding that occurs with several conditions, including the following: mitral stenosis, left bundle branch block, pericardial syndromes and severe pulmonary hypertension. We explore the subtle changes that occur on M-mode imaging of the septum, other associated echocardiographic features, the impact of inspiratory effort on septal motion and relevant clinical findings. Finally, we discuss the impact of abnormal septal motion on cardiac form and function, proposing there is a clinically significant impact on biventricular filling and ejection.

In patients with septic shock, a correlation between positive fluid balance and worsened outcomes has been reported in multiple observational studies worldwide. No published data exists in an Australasian cohort. We set out to explore this association in our institution. We conducted a retrospective audit of patient records from August 2012 to May 2015 in a single-centre, 24-bed surgical and medical intensive care unit (ICU) in Sydney, Australia. All patients with septic shock were included. Exclusion criteria included length of stay less than 24 hours or vasopressors needed for less than six hours. Data was gathered on fluid balance for the first seven days of ICU admission, biochemical data and other clinical indices. The primary outcome measure was survival to hospital discharge. One hundred and eighty-six patients with septic shock were included, with an overall hospital mortality of 23.7%. Seventy-five percent of patients required mechanical ventilation, and 27.4% required haemodialysis. The mean daily fluid balance on the first day of admission was positive 1,424 ml and 1,394 ml for ICU and hospital survivors, respectively. On average, the daily fluid balance for non-survivors was higher than the survivors: ICU non-survivors were 602 (95% confidence intervals 230, 974) ml (P=0.0015) and hospital non-survivors were 530 [95% confidence intervals 197, 863] ml (P=0.0017) higher than the survivors. In line with other recently published data, after adjustment for confounders (severity of illness based on the Acute Physiology and Chronic Health Evaluation score) we found a correlation between positive fluid balance and worsened hospital mortality in critically ill patients with sepsis and septic shock. Further research investigating rational use of fluids in this patient group is needed.

Background Despite the evidence for calibrated cardiac monitored devices to determine fluid responsiveness, there is minimal evidence that the use of cardiac output monitor devices leads to an overall change in IV fluid use. We sought to investigate the feasibility of performing a randomised controlled study using calibrated cardiac output monitoring devices in shocked ICU patients and whether the use of these devices led to a difference in total volume of IV fluid administered. Methods We performed a single-centre non-blinded randomised controlled study which included patients who met the clinical criteria for shock on admission to ICU. Patients were divided into two groups (cardiac output monitors or standard) by block randomisation. Patients allocated to the cardiac output monitor all received EV1000 with Volume View sets. Daily intravenous fluid administration and cumulative fluid balance was recorded for 3 days. The primary outcome assessed was the difference in daily intravenous fluid administration and cumulative fluid balance at 72 h between the two groups. We also assessed how often the clinicians used the cardiac monitor to guide fluid therapy and the different reasoning for initiating further intravenous fluids. Results Eighty patients were randomised and 37 received calibrated cardiac output monitors. We found no adverse outcomes in the use of calibrated cardiac output monitoring devices and that was feasible to perform a randomised controlled trial. There was no significant difference between the standard care group vs the cardiac monitoring group for cumulative fluid balance (2503 ± 3764 ml vs 2458 ± 3560 ml, p = 0.96). There was no significant difference between the groups for daily intravenous fluid administration on days 1, 2 or 3. In the cardiac monitored group, only 43% of the time was the EV1000 output incorporated into the decision to give further intravenous fluids. Conclusion It is feasible to perform a randomised controlled trial using calibrated cardiac output monitoring devices. In addition, there was no trend to suggest that the use of a cardiac monitors leads to lower IV fluid use in the shocked patient. Further trials will require study designs to optimise the use of a cardiac output monitor to determine the utility of these devices in the shocked patient. Trial registration ANZCTR, ACTRN12618001373268. Registered 15 August 2018—retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s40560-018-0356-y) contains supplementary material, which is available to authorized users.

Background Tricuspid annular plane systolic excursion (TAPSE) is frequently used as an objective measure of right-ventricular dysfunction. Abnormal TAPSE values are associated with poor prognosis in a number of disease states; however, the measure is not always easy to obtain in the critically ill. The purpose of this study is to assess the feasibility and accuracy of using a subcostal view and TAPSE measurement as a measure of right-ventricular dysfunction. A secondary aim was to perform a pilot study to assess whether right-ventricular dysfunction was associated with adverse outcomes including mortality. Results Subcostal TAPSE corresponds well with TAPSE obtained from the apical window at low and moderate TAPSE values (mean difference 1.2 mm (CI 0.04–2.36; 100% data pairs

A 60-year-old man was admitted to intensive care unit with the diagnosis of pulmonary embolism. Bedside transthoracic echocardiography revealed the extension of the thrombus into left atrium and ventricle through patent foramen ovale (PFO). A straddling thrombus also described as impending paradoxical embolism is a rare condition when thrombus embolised to the heart gets caught in PFO. Morbidity is extremely high in case of systemic embolisation. Due to rarity, the treatment options are mainly individualised and no guidelines exist. There are few treatment strategies described in literature from surgical to interventional radiology to conservative approach. Treatment strategy should take individual parameters such as patient’s age, haemodynamic stability, bleeding risk and comorbidities into consideration. Our patient successfully underwent emergency surgical thrombectomy.

Background Transthoracic 3D cardiac analysis is enticing in its potential simplicity and wealth of data available. It has been suggested to be accurate vs magnetic resonance imaging in relatively stable patients, but feasibility and agreement with conventional echocardiographic assessment of stroke volume (SV) have not been thoroughly assessed in critically ill patients, who are traditionally harder to image. The objectives of this study were to compare 3D transthoracic volumetric analysis vs Doppler assessment of SV (which is suggested to be accurate in the critically ill) and Simpson’s biplane assessment in a cohort typical of the intensive care unit (ICU), where accurate assessment is important: mechanically ventilated patients with a significant ventilation/perfusion (V/Q) mismatch. We hypothesised that it would be feasible but might lack agreement. Methods Patients were imaged within 24 hours of admission. Inclusion criteria were adult patients, V/Q mismatch present (defined as a ratio of arterial oxygen partial pressure to fractional inspired oxygen

To investigate the metabolic and cardiac effects of intravenous administration of two hypertonic solutions - 3% saline (SAL) and 0.5M sodium lactate (LAC).A randomised, doubleblind, crossover study in ten human volunteers. Intravenous bolus of either SAL or LAC at 3 mL/kg over 20 min followed by a 2 mL/kg infusion over 60 min.Acid base parameters and echocardiographic indices of cardiac function, cardiac output (CO), left ventricular ejection fraction (LVEF) and mitral annular peak systolic velocity (Sm) before and after infusion of SAL or LAC.Despite haemodilution, we observed an increase in sodium (139 ± 2 mmol/L to 142 ± 2 mmol/L in both groups) and respective anions, chloride (106 ± 2 mmol/L to 112 ± 3 mmol/L) and lactate (1.01 ± 0.28 mmol/L to 2.38 ± 0.38 mmol/L) with SAL and LAC, respectively. The pH (7.37 ± 0.03 to 7.45 ± 0.03; P0.01) and simplified strong ion difference (SID) (36.3 ± 4.6 mmol/L to 39.2 ± 3.6 mmol/L; P0.01) increased during the LAC infusion. The pH was unchanged, but SID decreased during SAL infusion (36.3 ± 2.5 mmol/L to 33.9 ± 3.1 mmol/L; P = 0.01). Both solutions led to an increase in preload and cardiac function, CO (4.36 ± 0.79 L/min to 4.98 ± 1.37 L/ min v 4.62 ± 1.30 L/min to 5.13 ± 1.44 L/min), LVEF (61 ± 6% to 63 ± 8% v 64 ± 6% to 68 ± 7%). The averaged Sm improved in the LAC group as compared with the SAL group (0.088 ± 0.008 to 0.096 ± 0.016 v 0.086 ± 0.012 to 0.082 ± 0.012; P = 0.032).The administration of SAL or LAC has opposing effects on acid base variables such as SID. Hypertonic fluid infusion lead to increased cardiac preload and performance with Sm, suggesting better left ventricular systolic function during LAC as compared with SAL. Lactated hypertonic solutions should be evaluated as resuscitation fluids.

To describe the technique and review the utility of bedside lung ultrasound in acute care.Lung ultrasound is a useful point-of-care investigation in acute care, especially in patients with dyspnoea or haemodynamic instability. Although normal lung parenchyma is not accessible to ultrasound, distinctive artefacts arising from parietal and visceral pleura indirectly imply the presence of normal lung. As aeration of lung tissue reduces with disease process, visual assessment of several pathologic entities by ultrasound becomes possible. Ultrasound can be used for qualitative and quantitative assessment as well as to guide intervention. Compared with supine anteroposterior chest x-rays, lung ultrasound is faster and superior at ruling out pneumothorax and diagnosing lung consolidation, pleural effusions or pulmonary oedema. It is a logical and highly valuable extension of echocardiography and can be incorporated into diagnostic algorithms for assessment of dyspnoea, hypotension, chest pain or trauma. It provides rapid information about potentially reversible pathology in cardiac arrest scenarios. Other advantages include bedside availability, repeatability, provision of dynamic diagnostic information, ease of use and the absence of radiation exposure.

Background Left ventricular diastolic dysfunction is suggested to be associated with higher mortality in severe sepsis and septic shock, yet the methods of diagnosis described in the literature are often inconsistent. The recently published 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging (ASE/EACVI) guidelines offer the opportunity to apply a simple pragmatic diagnostic algorithm for the detection of diastolic dysfunction; however, it has not been tested in this cohort. Aims We sought to assess the applicability in septic patients of recently published 2016 ASE/EACVI guidelines on diastolic dysfunction compared with the 2009 ASE guidelines. Our hypothesis was that there would be poor agreement in classifying patients. Methods Prospective observational study includes patients identified as having severe sepsis and septic shock. Patients underwent transthoracic echocardiography on day 1 and day 3 of their ICU admission. Patients with normal and abnormal (ejection fraction

Critical care echocardiography is developing rapidly with an increasing number of specialists now performing comprehensive studies using Doppler and other advanced techniques. However, this imaging can be challenging, interpretation is far from simple in the complex critically ill patient and mistakes can be easy to make. We aim to address clinically relevant areas where potential errors may occur and suggest methods to hopefully improve accuracy of imaging and interpretation.

Background Assessment of competence in basic critical care echocardiography is complex. Competence relies on not only imaging accuracy but also interpretation and appropriate management decisions. The experience to achieve these skills, real-time, is likely more than required for imaging accuracy alone. We aimed to assess the feasibility of using simulation to assess number of studies required to attain competence in basic critical care echocardiography. Methods This is a prospective pilot study recruiting trainees at various degrees of experience in basic critical care echocardiography using experts as reference standard. We used high fidelity simulation to assess speed and accuracy using total time taken, total position difference and total angle difference across the basic acoustic windows. Interpretation and clinical application skills were assessed using a clinical scenario. ‘Cut-off’ values for number of studies required for competence were estimated. Results Twenty-seven trainees and eight experts were included. The subcostal view was achieved quickest by trainees (median 23 s, IQR 19–37). Eighty-seven percent of trainees did not achieve accuracy across all views; 81% achieved accuracy with the parasternal long axis and the least accurate was the parasternal short axis (44% of trainees). Fewer studies were required to be considered competent with imaging acquisition compared with competence in correct interpretation and integration (15 vs. 40 vs. 50, respectively). Discussion The use of echocardiography simulation to determine competence in basic critical care echocardiography is feasible. Competence in image acquisition appears to be achieved with less experience than correct interpretation and correct management decisions. Further studies are required.

Echocardiography is developing rapidly. Speckle tracking echocardiography is the latest semi-automatic tool that has potential to quantitatively describe cardiac dysfunction that may be unrecognised by conventional echocardiography. It is a non-Doppler, angle-independent, feasible and reproducible method to evaluate myocardial function in both non–critically ill and critically ill populations. Increasingly it has become a standard measure of both left and right ventricle function in specific patient groups, e.g. chemotherapy-induced cardiomyopathy or pulmonary hypertension. To date there are few studies in the critically ill, predominantly in sepsis, yet all describe dysfunction beyond standard measures. Other areas of interest include heart–lung interactions, right ventricle function and twist and torsion of the heart. A word of caution is required, however, in that speckle tracking echocardiography is far from perfect and is more challenging, particularly in the critically ill, than implied by many published studies. It takes time to learn and perform and most values are not validated, particularly in the critically ill. We should be cautious in accepting that the latest software used in cardiology cohorts will automatically be the answer in the critically ill. Even with these limitations the technology is enticing and results fascinating. We are uncovering previously undescribed dysfunction and although it currently is essentially a research-based activity, there is great promise as a clinical tool as echocardiography analysis becomes more automated, and potentially speckle tracking echocardiography could help describe cardiac function in critical illness more accurately than is possible with current techniques.

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes (T1D), which without treatment leads to death. Fulminant type 1 diabetes (FT1D) is a subtype characterised by a markedly rapid and almost complete destruction of pancreatic β-cells, with acute onset leading to severe metabolic derangement and commonly ICU admission. We present a case of an 18-year-old male presenting with FT1D with two rare complications of pneumomediastinum and stress-induced cardiomyopathy (SIC) with significant myocardial necrosis. We also discuss the aetiology of the pneumomediastinum; the latest thoughts on SIC: moving beyond the simple description of ‘Takotsubo cardiomyopathy’; the role of troponins in critical illness; and genetic predisposition for DKA due to FT1D.