Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

Abstract

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to “collateral damage” in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

Cytokine Storm of COVID-19 and its Impact on Patients with and without Chronic Liver Disease

“…Improved intensive care, timely interventions and monitoring altered liver chemistries can improve outcomes. 53 Other associations, such as presence of chronic hepatitis B, did not increase the mortality risk. Therefore, it appears that the cytokine storm is one of the important defining fac- tors contributing to morbidity and mortality in those with liver disease.…”

Prevention, diagnostic evaluation, management and prognostic implications of liver disease in critically ill patients with COVID-19

“…Moreover, they have limitations in critically ill patients with liver failure such as the presence of ascites (extravascular third space fluid) or hepatic hydrothorax (extravascular lung water), which confuse the measurements and the lack of validation of these techniques on such patients. Remote point-of-care ultrasonography (POCUS) by a hepatologist or an ICU physician, with real-time interpretation by a cardiologist through telemedicine, is a trend that has been adopted in the COVID-19 era[ 79 ]. Information on the hemodynamic status and the cause of the hemodynamic compromise of these patients is safely and accurately collected.…”

Acute liver injury in COVID-19 patients hospitalized in the intensive care unit: Narrative review

“…In order to achieve optimal loading conditions, a multimodal approach should be adopted, whereby fluid resuscitation should be guided by physical examination, follow-up of vital signs, lactate levels, dynamic parameters and point-of-care ultrasonography[ 120 ]. It has been proposed that a systematic approach incorporating focused echocardiography, lung scanning and abdominal ultrasound may facilitate the bedside evaluation of cardiac function, volume status and fluid responsiveness, while at the same time it can aid in the differential diagnosis of an undifferentiated shock, as well as in the detection of biliary or hepatic sepsis, intraabdominal fluid collection and other acute pathologies[ 174 - 176 ].…”