Intensivists

Dr. Elapavaluru

Hemodynamic Ultrasound for Intensivists and Attending Physicians

Dr. Subbarao Elapavaluru MD, CVICU, an intensivist at Allegheny General in Pittsburgh, says he knew how to help a clot-compressed patient “as soon as he inserted the hTEE probe.”

Main Takeaways

  • Dr. Elapavaluru says the ImaCor hTEE 3-Step Method “makes a big difference for immediate postop care,” especially the first 6-12 hours.
  • hTEE has helped him make quick decisions for clots, hematomas, titrating, tamponade, and RV dysfunction.
  • Dr. Elapavaluru says hTEE is “particularly effective” after LVAD and for cardiogenic and vasoplegic patients.

Excerpts from our Interview

ImaCor: Why do you use hemodynamic ultrasound in your CVICU, Doctor?

Dr. Elapavaluru: Well, we are in a post-operative cardiac surgery ICU and this tool makes a big difference for immediate postop care.

During post-op care of a critically ill patient for hemodynamic monitoring, titration of drips, and for coagulopathic patients, if I have to make a decision between RV dysfunction and a tamponade physiology, this plays a big role.

ImaCor: Thank you. How has hemodynamic ultrasound impacted your patient population?

Dr. Elapavaluru: My colleagues, cardiac surgeons, and I find the immediate first 6-12 hours of post-op care is where we find the most utility, primarily in our high-risk populations for:

Monitoring RV dysfunction following an LVAD (left ventricular assist device) placement;

Cardiogenic shock VA ECMO (ECMO with ventilation) patients; and,

Helping in weaning of inotropic invasive active agents.

ImaCor: Thank you. Can you identify a specific patient case where hTEE made an insignificant difference in the outcome?

Dr. Elapavaluru: Our group has been using this tool now since 2013. Each of our intensivists has had a good experience and knows how to use the tool.

From my own experience, it’s helped me make important decisions that helped our surgeons make quick decisions to evacuate blood clots and hematomas, as well as titrating and following up on agents.

Recently, a patient with a valve and CABG (coronary artery bypass surgery) was oozing coagulopathically and within six hours of coming to the CVICU, his CVP (central venous pressure) increased.

We suspected tamponade, but he had an unexplained desaturation, so as soon as we placed the probe we knew we were dealing with a clot compression instead of looking into other causes of hypoxemia. In the case, we were able to make a quick decision to evacuate the clot.

ImaCor: That is a fantastic story. When do you normally first reach for hTEE? When a patient comes up? After some delay? Or do you determine the best course of action in each case?

Dr. Elapavaluru: We use hTEE on an as-needed basis, but I will say there is a pattern. We’ve identified this in the last four years.

We find hTEE is particularly effective for a certain group of patients, in particular:

After left ventricular assist device placement – for monitoring dysfunction;

After high-risk valve surgeries;

For cardiogenic shock patient management; and,

For patients who are intensely vasoplegic and require titration.

ImaCor: Thank you, Doctor. One last question: Have you been able to wean patients off ventilation easier and sooner with hTEE technology?

Dr. Elapavaluru: Absolutely. But the bigger impact has been being able to wean patients off pressors faster. As a result, we can wean off the ventilator faster too.

Are her interventions working?

Certified Nurse Practitioner Genevieve Dobrushin used invasive hemodynamic monitoring devices including catheters, but those didn’t show cardiac filling and function.

Genevieve Dobrushin