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Minerva Anestesiologica 2020 Aug 04

DOI: 10.23736/S0375-9393.20.14613-3

Copyright © 2020 EDIZIONI MINERVA MEDICA

lingua: Inglese

Management of cardiovascular insufficiency in ICU: the BEAT approach

Fabio GUARRACINO 1 , Pietro BERTINI 1, Michael R. PINSKY 2

1 Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy; 2 Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA


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A large number of patients admitted to ICU display hemodynamic deterioration at some time during their stay. The management of acute hemodynamic derangement of any cause can be difficult and has to be accomplished quickly and correctly as delayed and inappropriate resuscitation treatments carry increased mortality. Cardiovascular insufficiency shows end-organ hypoperfusion-associated dysfunction, thus decreasing level of consciousness, falling urine output, ileus, new onset tachypnea and the presence of skin mottling are important clinical clues to cardiovascular deterioration and should be promptly looked for and if detected alert the bedside clinician that further assessment and potentially treatment is necessary. Although measures of serum lactate are useful to document the presence of tissue hypoperfusion, they are non-specific in defining its etiology. In a patient with acute hemodynamic instability, we propose a step-by-step approach as follows: 1) rapid initial ultrasound assessment of heart function: we recommend immediate transthoracic echocardiogram in any patient with acute hemodynamic alteration before starting specific treatments. 2) pathophysiological understanding of heart and circulation interaction: we recommend using a non-invasive approach to assess ventriculo-arterial coupling. 3) functional hemodynamic monitoring: we recommend using a functional hemodynamic monitoring (FHM) approach with passive leg raising manoeuvre (PLR) in all patients. 4) treatment: we recommend to treat the hemodynamic derangement based on the echocardiographic evaluation and pathophysiological understanding improved by assessing the interaction between the heart and the circulation. We named such approach BEAT, which stands for: Browse the heart, measure the Elastances, Assess volume status, and Treat. Combining bedside echocardiography, including the evaluation of the interaction between the heart and the circulation, with FHM offers the opportunity to personalise the hemodynamic management to the specific requirements.


KEY WORDS: Ventriculo-arterial coupling; Functional Hemodynamic Monitoring; Hemodynamics; Echocardiography; Critical Care

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