Transesophageal echocardiography in critically ill patients

Transesophageal echocardiography-associated gastrointestinal injuries: systematic review and pooled rates of gastrointestinal injuries

Upper gastrointestinal (GI) injuries are associated with transesophageal echocardiography (TEE) complications. We reviewed rates and various types of complications with GI injuries. A comprehensive literature search using five databases was conducted. Pooled rates were calculated for overall injuries, pooled GI complications, lacerations, and perforations with a 95% confidence interval (CI). A total of 26 studies involving 55,319 patients met inclusion criteria. The overall rate of adverse events was 0.51% (95% CI 0.3% to 0.7%). Bleeding was the most commonly reported adverse event, followed by dysphagia and lacerations. The highest rate of adverse events was observed in liver transplant patients (1.35%), followed by critically ill patients in the intensive care unit (1.1%), hospitalized patients (1.1%), patients undergoing intraoperative TEE (0.7%), and those undergoing cardiac procedures (0.67%). The pooled complication rate for bleeding was 0.17% (95% CI 0.1% to 0.3%), while odynophagia/dysphagia had a rate of 0.27% (95% CI -0.1% to 0.5%) and lacerations had a rate of 0.12% (95% CI -0.1% to 0.5%). A subgroup analysis comparing variceal and nonvariceal cohorts from three studies showed no significant difference in bleeding rates. Our study findings showed a low risk of esophageal injury in patients undergoing TEE.

Focused Ultrasonography in Cardiac Arrest

Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.

Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review

BACKGROUND

Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) - lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE.

METHODS

MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate.

RESULTS

Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported.

CONCLUSIONS

The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.

Cardiac contusions in the acute care setting: Historical background, evaluation and management

INTRODUCTION

Albeit described since 1763, cardiac contusions is still an under-recognised clinical condition in the acute care setting. This evidence-based review aims to provide an overview of the topic by focusing on etiopathogenesis, classification and clinical presentation of patients with cardiac contusions, as well as on the diagnostic work-up and therapy options available for this subset population in the acute care setting.

METHODS

A targeted research strategy was performed using PubMed, MEDLINE, Embase and Cochrane Central databases up to June 2022. The literature search was conducted using the following keywords (in Title and/or Abstract): ("cardiac" OR "heart" OR "myocardial") AND ("contusion"). All available high-quality resources written in English and containing information on epidemiology, etiopathogenesis, clinical findings, diagnosis and management of cardiac contusions were included in our research.

RESULTS

Biochemical samples of cardiac troponins together with a 12‑lead ECG appear to be sufficient screening tools in hemodynamically stable subjects, while cardiac ultrasound provides a further diagnostic clue for patients with hemodynamic instability or those more likely to have a significant cardiac contusion.

CONCLUSIONS

The management of patients with suspected cardiac contusion remains a challenge in clinical practice. For this kind of patients a comprehensive diagnostic approach and a prompt emergency response are required, taking into consideration the degree of severity and clinical impairment of associated traumatic injuries.

Feasibility, utility, and safety of fully incorporating transesophageal echocardiography into emergency medicine practice

INTRODUCTION

Transthoracic echocardiography (TTE) is a standard procedure for emergency physicians (EPs). Transesophageal echocardiography (TEE) is known to have great utility in patients who are critically ill or in cardiac arrest and has been used by some EPs with specialized ultrasound (US) training, but it is generally considered outside the reach of the majority of EPs. We surmised that all of our EPs could learn to perform focused TEE (F-TEE), so we trained and credentialed all of the physicians in our group.

METHODS

We trained 52 EPs to perform and interpret F-TEEs using a 4-h simulator-based course. We kept a database of all F-TEE examinations for quality assurance and continuous quality feedback. Data are reported using descriptive statistics.

RESULTS

Emergency physicians attempted 557 total F-TEE examinations (median = 10, interquartile range = 5-15) during the 42-month period following training. Clinically relevant images were obtained in 99% of patients. EPs without fellowship or other advanced US training performed the majority of F-TEEs (417, 74.9%) and 94.3% (95% confidence interval [CI] = 91.4%-96.3%) had interpretable images recorded. When TTE and TEE were both performed (n = 410), image quality of TEE was superior in 378 (93.3%, 95% CI = 89.7%-95%). Indications for F-TEE included periarrest states (55.7%), cardiac arrest (32.1%), and shock (12.2%). There was one case of endotracheal tube dislodgement during TEE placement, but this was immediately identified and replaced without complication.

CONCLUSION

After initiating a mandatory group F-TEE training and credentialing program, we report the largest series to date of EP-performed resuscitative F-TEE. The majority of F-TEE examinations (75%) were performed by EPs without advanced US training beyond residency.

Prospective evaluation of complications associated with transesophageal echocardiography in dogs with congenital heart disease

Background

Transesophageal echocardiography (TEE) is useful in the assessment and procedural monitoring of congenital heart disease (CHD) with a relatively low complication rate in humans.

Objectives

To evaluate the safety of TEE and report complications in dogs.

Animals

Forty client‐owned dogs with CHD.

Methods

Prospective observational study including gastroesophagoscopy before and after TEE imaging. TEE was planned with a GE 6VT‐D adult probe in dogs weighing ≥4 kg and a GE 10T‐D microprobe alternating with an intracardiac echocardiography probe placed in the esophagus in dogs <4 kg. Difficulties with probe placement, probe interference and TEE probe imaging times were recorded. Dogs were monitored in the recovery period after TEE using an established nausea scoring system.

Results

New gastroesophageal abnormalities were identified after TEE in 4 dogs including 4 areas of mucosal damage involving <25% of the lower esophageal sphincter (n = 4) and 1 lesion at the heart base (n = 1) and were not attributed to longer imaging times or a specific probe. Lesions identified before TEE in 4 dogs remained unchanged after TEE. The 6VT‐D probe could not be placed in 1 dog with enlarged tonsils, and it obstructed fluoroscopic views in 3 dogs. The probes did not compress any structures in dogs in which fluoroscopy was performed (n = 20). Four dogs had evidence to suggest nausea after the procedure.

Conclusions and Clinical Importance

While major complications remain possible, complications in this study were mild and few in number. Dog size and probe characteristics are factors to consider when performing TEE.

Role of Ultrasound in Neurocritical Care

Bedside point of care ultrasound has acquired an extremely significant role in diagnosis and management of neurocritical care, just as it has in other specialties. Easy availability and increasing expertise have allowed the intensivists to use it in a wide array of situations, such as confirming clinical findings as well as for interventional and prognostic purposes. At present, the clinical applications of ultrasonography (USG) in a neurosurgical patient include estimation of elevated intracranial pressure (ICP), assessment of cerebral blood flow (CBF) and velocities, diagnosis of intracranial mass lesion and midline shifts, and examination of pupils, apart from the systemic applications. Transcranial sonography has also found use in the diagnosis of the cerebral circulatory arrest. An increasing number of clinicians are now relying on the use of ultrasound in the neurointensive care unit for neurological as well as non-neurological indications. These uses include the diagnosis of shock, respiratory failure, deep vein thrombosis and performing bedside procedures.

Unanticipated critical findings on echocardiography in septic patients

BACKGROUND

Echocardiography is increasingly performed among septic patients as a routine part of evaluation and management in the intensive care unit (ICU). The rate of unanticipated critical findings (e.g., severe left or right ventricular dysfunction or pericardial tamponade) on such echocardiograms is unknown. We evaluated a retrospective cohort of septic ICU patients in whom transthoracic echocardiography was performed as a routine part of sepsis management. In addition to identifying critical findings, we defined whether each critical finding was anticipated, and whether the clinical team responded to the critical finding. The primary outcome was rate of unanticipated critical findings, which we hypothesized would occur in fewer than 5% of patients. We also performed an exploratory analysis of the association between unanticipated critical finding and mortality, controlling for severity of illness.

RESULTS

We studied 393 patients. Unanticipated critical findings were identified in 5% (95% CI 3-7%) of patients (n = 20). Among the 20 patients with unanticipated critical findings, a response to the unanticipated critical finding was identified in 12 (60%) patients. An unanticipated critical finding was not significantly associated with 28-day mortality when controlling for admission APACHE II (p = 0.27).

CONCLUSIONS

Unanticipated critical findings on echocardiograms in septic ICU patients are uncommon. The potential therapeutic relevance of echocardiography to sepsis is more likely related to hemodynamic management than to traditional cardiac diagnoses. Research studies that employ blinded echocardiograms in septic patients may anticipate unblinding for critical findings approximately 1 in every 20 echocardiograms.

Impact of goal directed basic echocardiography on diagnostic and therapeutic management in an ICU of cardiac surgery

OBJECTIVE

Few studies have evaluated the impact in diagnosis and therapeutic management of basic transthoracic echocardiography in postoperated cardiac surgery. The aim of our study was to evaluate the impact of basic transthoracic echocardiography in the management of this kind of patients.

DESIGN

Over an 18-month period, we prospectively studied all patients admitted to a university hospital Intensive Care Unit following heart surgery. We evaluated clinically all of them to establish a diagnosis and an initial treatment. We performed basic transthoracic echocardiography for a diagnosis evaluation that was compared with clinical diagnosis. If they differed, we assessed to change treatment and evaluate the therapeutic response. We performed a descriptive analysis.

RESULTS

We included 136 patients and performed 203 echocardiographies. Transthoracic echocardiography differed of initial diagnosis in 101 (49.8%) echocardiographies. In 56 of these echocardiographies (55.44%), we could give an alternative diagnosis with a change in the treatment in 30patients (53,6%). We found clinical improvement in 26 patients (86.76%) in the following 30-60minutes.

CONCLUSIONS

Basic transthoracic echocardiography is useful in diagnostic and therapeutic management of postoperative cardiac surgery patients. We could not confirm the clinical diagnosis in half of the performed echocardiographies. In most patients in whom we observe a change in the diagnosis due to echocardiography, we observed a clinical improvement after changing the treatment.

Role of Echocardiography in the Intensive Care Unit: Overview of the Most Common Clinical Scenarios

The intensive care unit (ICU) is among the more important settings in which echocardiography plays a pivotal role. The ease of use, speed of execution, and completeness of information on heart anatomy and function that echocardiography is able to provide makes this tool the perfect diagnostic technique in patients for whom exhaustive information must be quickly obtained by physicians who sometimes lack specific skills in cardiovascular imaging. However, the clinical entities encountered by ICU clinicians are often difficult to distinguish and patient symptoms may not be obvious. This brief review describes three common clinical scenarios that benefit from echocardiography in the ICU, based on symptoms frequently claimed by patients admitted to the ICU. For each symptom we describe the most likely clinical possibilities, underlining the fundamental role that echocardiography plays in the differential diagnosis, and the echocardiographic elements most relevant to obtain the correct diagnosis and to guide treatment.

Better With Ultrasound: Transesophageal Echocardiography

Transesophageal echocardiography (TEE) is a safe and minimally invasive tool that can routinely provide high-quality anatomic and hemodynamic information in the severely ill. Despite its potential for frontline acute care clinicians, TEE use has typically been reserved for diagnostic experts in the cardiac-surgical milieu. With the continued evolution of point-of-care ultrasound into increasingly sophisticated domains, TEE has gained steady uptake in many nontraditional environments for both advanced echocardiographic assessment as well as answering more goal directed, fundamental questions. This article introduces the workings of the TEE transducer, presents a systematic approach to a goal-directed hemodynamic assessment, and includes a series of illustrative figures and narrated video presentations to demonstrate the techniques described.

Impact of Critical Care Transesophageal Echocardiography in Medical-Surgical ICU Patients: Characteristics and Results From 274 Consecutive Examinations

OBJECTIVE

Critical care echocardiography has become an integral tool in the assessment and management of critically ill patients. Critical care transesophageal echocardiography (TEE) offers diagnostic reliability, superior image quality, and an expanded diagnostic scope to transthoracic echocardiography. Despite its favorable attributes, TEE use in North American intensive care units (ICUs) remains relatively undescribed. In this article, we seek to characterize the feasibility, indications, and clinical impact of a critical care TEE program.

DESIGN

Retrospective, observational study.

SETTING

Tertiary care, academic critical care program consisting of 2 hospitals in Ontario, Canada.

PARTICIPANTS

Consecutive critical care TEE examinations on ICU patients performed between December 2012 and December 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Consecutive critical care TEE studies on ICU patients from December 1, 2012, to December 31, 2016, were reviewed. The TEEs performed on cardiac surgery patients and those without reports were excluded. Examination details, including indications, complications, examination complexity (number of views, Doppler techniques), and clinical recommendations were aggregated and analyzed. Two hundred seventy-four TEE studies were performed by 38 operators. Common indications for TEE studies were hemodynamic instability (45.2%), assessment for infective endocarditis (22.2%), and cardiac arrest (20.1%). A change in patient management was proposed following 79.5% of TEE studies. Thirty-eight percent of TEE studies were performed during evening hours or on weekends. There were no mechanical complications.

CONCLUSIONS

Our observational data support intensivist-performed TEE as being safe and therapeutically influential across a broad range of indications. Our program's demonstrated feasibility and impact may act as a model for TEE adoption in other North American ICUs.

Evaluation of intensivist basic training in transthoracic echocardiography in the postoperative period of heart surgery

BACKGROUND

Transthoracic echocardiography can significantly change the management of many critical patients, and is being incorporated into many Intensive Care Units (ICU). Very few studies have examined the feasibility and impact of intensivists performing basic transthoracic echocardiography upon the management of critical patients after cardiac surgery. The present study therefore evaluates the quality of acquisition and accuracy of intensivist interpretation of basic transthoracic echocardiograms in the postoperative period of heart surgery.

METHODS

Over an 8-month period we prospectively studied 148 patients within 24h after admission to a university hospital ICU following heart surgery. We performed basic transthoracic echocardiography to evaluate ventricular function, pericardial effusion, hypovolemia and mitral regurgitation. Cohen's Kappa was used to compare transthoracic echocardiograms obtained by intensivists with basic versus advanced training. Concordance on image acquisition and interpretation was evaluated.

RESULTS

We analyzed data of adequate transthoracic echocardiograms in 148 patients (92.5%). Apical four-chamber view and advanced trainees obtained better quality images. Concordance was good for right and left ventricular function (kappa=0.7±0.14 and 0.87±0.05, respectively), and moderate for the remaining parameters. Interpretation concordance between basic and advanced training intensivists was good (kappa=0.73±0.05).

CONCLUSIONS

Intensivists with basic training in echocardiography are capable of performing and interpreting echocardiograms in most patients during the postoperative period of heart surgery.

Perioperative transesophageal echocardiography for non-cardiac surgery

PURPOSE

The use of transesophageal echocardiography (TEE) has evolved to include patients undergoing high-risk non-cardiac procedures and patients with significant cardiac disease undergoing non-cardiac surgery. Implementation of basic TEE education in training programs has increased across a broad spectrum of procedures in the perioperative arena. This paper describes the use of perioperative TEE in non-cardiac surgery and provides an overview of the basic TEE examination.

PRINCIPAL FINDINGS

Perioperative TEE is used to monitor hemodynamic parameters in non-cardiac procedures where there is a high risk of hemodynamic instability. Its use extends to include moderate-risk procedures for patients with significant cardiac diseases such as low ejection fraction, hypertrophic cardiomyopathy, severe valve lesions, or congenital heart disease. Vascular procedures involving the aorta, blunt trauma, and liver transplantation are all examples of procedures that may benefit from TEE. Transesophageal echocardiography examination allows assessment of volume status, ventricular function, diagnosis of gross valvular pathology and pericardial tamponade, as well as close monitoring of cardiac output, response to therapy, and the impact of ongoing surgical manipulation. In patients with unexplained and unexpected hemodynamic instability, "rescue TEE" can be used to help identify the underlying cause.

CONCLUSIONS

Perioperative TEE is emerging as a preferred tool to manage hemodynamics in high-risk procedures and in high-risk patients undergoing non-cardiac surgery. A rescue TEE examination protocol is a helpful approach for early identification of the etiology of hemodynamic instability.

Focused cardiac ultrasound in the early resuscitation of severe sepsis and septic shock: a prospective pilot study

PURPOSE

Point-of-care ultrasonography has been increasingly used in the care of critically ill patients; however, reports on its use during active resuscitation are limited. The aim of this study was to investigate the true impact of focused cardiac ultrasound (FCU) during the management of sepsis with early (6-h) resuscitation.

METHODS

A prospective pilot observational study was conducted at an academic medical center from March 2011 through July 2012. Patients undergoing resuscitation for severe sepsis or septic shock were prospectively enrolled at medical and combined medical-surgical intensive care units. Patients underwent a 10-min FCU examination when echocardiography was not part of their care plan. FCU was performed by sonographers and interpreted by cardiologists to minimize risks of inadequate image acquisition and misinterpretation. Intensivists completed surveys on their diagnostic and therapeutic plans before and after receiving FCU information.

RESULTS

Of the 30 patients enrolled, 18 (60%) were male and the median age was 61 years [interquartile range (IQR) 50-71 years]. Median central venous oxygen saturation and lactate levels were 59.6% (IQR 53.1-66.2%) and 2.7 mmol/L (IQR 1.2-4.1 mmol/L), respectively. Clinical assessment by intensivists before FCU commonly failed to correctly estimate ventricular function; specifically, left ventricular in 12 patients [40%, 95% confidence interval (CI) 25-58%] and right ventricular function in 15 patients (50%, 95% CI 33-67%). Intensivists' therapeutic plans changed in eight cases (27%, 95% CI 14-44%) after FCU information became available. The most common changes were fluid management and imaging tests. Intensivists' confidence in their therapeutic plans improved for 11 patients (37%, 95% CI 22-55%).

CONCLUSION

FCU is a valuable examination tool during early resuscitation of severe sepsis and septic shock.

Echocardiographic approach to cardiac tamponade in critically ill patients

Cardiac tamponade should be considered in a critically ill patient in whom the cause of haemodynamic shock is unclear. When considering tamponade, transthoracic echocardiography plays an essential role and is the initial investigation of choice. Diagnostic sensitivity of transthoracic echocardiography is dependent on image quality, and in some cases a transoesophageal approach may be required to confirm the diagnosis. Knowledge of the pathophysiology and echocardiographic features of cardiac tamponade are essential for the practicing Intensivist. This review presents an approach to the recognition, diagnosis, and treatment of cardiac tamponade in critically ill patients.

Safety of transesophageal echocardiography during extracorporeal life support

INTRODUCTION:

Use of extracorporeal life support (ECLS) has significantly increased in critically ill patients refractory to medical management. ECLS requires systemic anticoagulation to avoid thromboembolic complications and superimposed coagulopathies are common. Transesophageal echocardiography (TEE) is frequently employed to assess cannula position and cardiac function during extracorporeal therapy. The goal of this study was to assess whether TEE probe insertion and removal in systemically anticoagulated ECLS patients was safe compared to patients without ECLS and normal coagulation studies.

METHODS:

Eighty-seven separate TEE examinations in 53 adult ECLS patients were analyzed. Detailed complication profiles were logged for each patient from initiation through discontinuation of ECLS. Routine coagulation testing was recorded within two hours prior to the TEE exams. Controls consisted of age- and gender-matched patients undergoing perioperative TEE without ECLS and normal coagulation (N=87).

RESULTS:

Overall TEE-associated morbidity in ECLS patients was 2.3% and consisted of minor oropharyngeal bleeding (2/87 TEE exams) exclusively. The patients presenting with oropharyngeal bleeding received heparin for anticoagulation and had two or more abnormal coagulation studies at the time of TEE. Seventy-nine percent of ECLS patients received intravenous heparin infusions, 6.8% argatroban and 3.4% epoprostenol. Ten-point-eight percent of patients were not anticoagulated at the time of TEE because of pre-existing bleeding complications and/or deranged plasmatic coagulation profiles. No major complications (e.g., esophageal perforation, gastrointestinal bleeding, accidental extubation) were recorded in either group.

CONCLUSIONS:

TEE remained safe in critically ill patients under ECLS, despite systemic anticoagulation, during probe insertion, manipulation and removal. TEE-related complications pertained solely to oropharyngeal bleeding amenable to conservative management.

The Diagnostic and Therapeutic Impact of Point-of-Care Ultrasonography in the Intensive Care Unit

PURPOSE

In light of point-of-care ultrasonography's (POCUS) recent rise in popularity, assessment of its impact on diagnosis and treatment in the intensive care unit (ICU) is of key importance.

METHODS

Ultrasound examinations were collected through an ultrasound reporting software in 6 multidisciplinary ICU units from 3 university hospitals in Canada and the United States. This database included a self-reporting questionnaire to assess the impact of the ultrasound findings on diagnosis and treatment. We retrieved the results of these questionnaires and analyzed them in relation to which organs were assessed during the ultrasound examination.

RESULTS

One thousand two hundred and fifteen ultrasound studies were performed on 968 patients. Intensivists considered the image quality of cardiac ultrasound to be adequate in 94.7% compared to 99.7% for general ultrasound ( P < .001). The median duration of a cardiac examination was 10 (interquartile range [IQR] 10) minutes compared to 5 (IQR 8) minutes for a general examination ( P < .001). Overall, ultrasound findings led to a change in diagnosis in 302 studies (24.9%) and to a change in management in 534 studies (44.0%). A change in diagnosis or management was reported more frequently for cardiac ultrasound than for general ultrasound (108 [37.1%] vs 127 [16.5%], P < .001) and (170 [58.4%] vs 270 [35.1%], P < .001). Assessment of the inferior vena cava for fluid status emerged as the critical care ultrasound application associated with the greatest impact on management.

CONCLUSION

Point-of-care ultrasonography has the potential to optimize care of the critically ill patients when added to the clinical armamentarium of the intensive care physician.

Transthoracic and transoesophageal echocardiography: a systematic review of feasibility and impact on diagnosis, management and outcome after cardiac surgery

Transthoracic and transoesophageal echocardiography are increasingly used as tools to improve clinical assessment following cardiac surgery. However, most physicians are not trained in echocardiography, and there is no widespread agreement on the feasibility, indications or effect on outcome of transthoracic or transoesophageal echocardiography for patients after cardiac surgery. We performed a systematic review of electronic databases for focused transthoracic and transoesophageal echocardiography after cardiac surgery which revealed 15 full-text articles. They consistently reported that echocardiography is feasible, whether performed by a novice or expert, and frequently resulted in important changes in diagnosis of cardiac abnormalities and their management. However, most were observational studies and there were no well-designed trials investigating the impact of echocardiography on outcome. We conclude that both transthoracic and transoesophageal echocardiography are useful following cardiac surgery.

The Role of Focused Echocardiography in Pediatric Intensive Care: A Critical Appraisal

Echocardiography is a key tool for hemodynamic assessment in Intensive Care Units (ICU). Focused echocardiography performed by nonspecialist physicians has a limited scope, and the most relevant parameters assessed by focused echocardiography in Pediatric ICU are left ventricular systolic function, fluid responsiveness, cardiac tamponade and pulmonary hypertension. Proper ability building of pediatric emergency care physicians and intensivists to perform focused echocardiography is feasible and provides improved care of severely ill children and thus should be encouraged.

Clinician-performed ultrasound in hemodynamic and cardiac assessment: a synopsis of current indications and limitations

Accurate hemodynamic and intravascular volume status assessment is essential in the diagnostic and therapeutic management of critically ill patients. Over the last two decades, a number of technological advances were translated into a variety of minimally invasive or non-invasive hemodynamic monitoring modalities. Despite the promise of less invasive technologies, the quality, reliability, reproducibility, and generalizability of resultant hemodynamic and intravascular volume status data have been lacking. Since its formal introduction, ultrasound technology has provided the medical community with a more standardized, higher quality, broadly applicable, and reproducible method of accomplishing the above-mentioned objectives. With the advent of portable, hand-carried devices, the importance of sonography in hemodynamic and volume status assessment became clear. From basic venous collapsibility and global cardiac assessment to more complex tasks such as the assessment of cardiac flow and tissue Doppler signals, the number of real-life indications for sonology continues to increase. This review will provide an outline of the essential ultrasound applications in hemodynamic and volume status assessment, focusing on evidence-based uses and indications.

Echocardiographic estimation of mean pulmonary artery pressure in critically ill patients

Background

Indirect assessment of mean pulmonary arterial pressure (MPAP) may assist management of critically ill patients with pulmonary hypertension and right heart dysfunction. MPAP can be estimated as the sum of echocardiographically derived mean right ventricular to right atrial systolic pressure gradient and right atrial pressure; however, this has not been validated in critically ill patients.

Methods

This prospective validation study was conducted in patients undergoing pulmonary artery catheterisation during intensive care admission. Pulmonary artery catheter (PAC) measurements of MPAP were contemporaneously compared to MPAP estimated utilising transthoracic echocardiography (TTE)-derived mean right ventricular to right atrial systolic pressure gradient added to invasively measured right atrial pressure.

Results

Of 53 patients assessed, 23 had estimable MPAP using TTE. The mean difference between TTE- and PAC-derived MPAP was 1.9 mmHg (SD 5.0), with upper and lower limits of agreement of 11.6 and −7.9 mmHg, respectively. The median absolute percentage difference between TTE- and PAC-derived MPAP was 7.5%. Inter-rater reliability assessment was performed for 15 patients, giving an intra-class correlation coefficient of 0.96 (95% confidence intervals, 0.89 to 0.99).

Conclusions

This echocardiographic method of estimating MPAP in critically ill patients was not equivalent to invasively measured MPAP, based on our predefined clinically acceptable range (±5 mmHg). The accuracy of this method in critically ill patients was similar to the results obtained in ambulatory patients and compared favourably with regard to the accuracy with echocardiographic estimation of systolic pulmonary arterial pressure. The utility of this technique is limited by frequent inability to obtain an adequate tricuspid regurgitant time-velocity integral in critically ill patients.

Transthoracic echocardiography in pediatric intensive care: impact on medical and surgical management

OBJECTIVES

Although transthoracic echocardiography is commonly performed in the PICU, its utility is not specifically known. The purpose of this investigation was to evaluate the clinical impact of echocardiography in the PICU in terms of frequency of unanticipated findings and the frequency and nature of clinical management changes attributed to the results of echocardiography.

DESIGN

Prospective cohort study.

SETTING

Nineteen-bed combined medical-surgical-cardiac PICU at a tertiary care children's hospital.

PATIENTS

All patients in PICU undergoing transthoracic echocardiography.

INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS

Data collected included echocardiography indications, pre-echocardiography clinical assessment of anticipated echocardiography findings, height, weight, primary diagnosis, age, and urgency (stat vs routine) of echocardiography. Input of the attending care team (intensivist, cardiologist, and/or cardiovascular surgeon) allowed classification of echocardiography results as either confirming the pre-echocardiography impression, altering the pre-echocardiography clinical impression regarding the indication for which the test was performed, or altering the impression by virtue of new findings unrelated to the specific indication. The nature of the new findings were recorded and categorized. The team recorded clinical management changes made in response to the echocardiography results; the nature of these were listed and categorized. Echocardiograms (n = 416) were performed in 132 patients. Of these, 244 echocardiograms (59%) were ordered on male patients, 31% were under 30 days old, median age was 103 days, 379 (91%) had a primary cardiac diagnosis, and 92 (22%) were ordered stat. Sixty-three percent of echocardiograms confirmed and 24% altered the pre-echocardiography impression regarding the indication for the echocardiography; 13% introduced new findings unrelated to the indication. Cardiac surgical revision was the management change required in 26 patients (6.3%). Stat echocardiography was more likely to alter the pre-echocardiography assessment than routine echocardiography (p < 0.001). Management changes were more commonly associated with stat echocardiograms (p = 0.002) and those with new unexpected findings (p < 0.001) but had no demonstrable association with age less than 30 days (p = 0.332).

CONCLUSIONS

Unanticipated echocardiography results are common in the PICU, and they often alter the clinical impressions that prompted the echocardiogram or introduce new findings unrelated to the reason for which the echocardiogram was recorded. Clinical management changes attributable to echocardiography findings are frequent in the PICU, including occasional surgical intervention. Echocardiography adds diagnostic value and contributes to the management approach in the PICU, accounting for its frequent use.

Focused critical care echocardiography

OBJECTIVE

Portable ultrasound is now used routinely in many ICUs for various clinical applications. Echocardiography performed by noncardiologists, both transesophageal and transthoracic, has evolved to broad applications in diagnosis, monitoring, and management of critically ill patients. This review provides a current update on focused critical care echocardiography for the management of critically ill patients.

METHOD

Source data were obtained from a PubMed search of the medical literature, including the PubMed "related articles" search methodology.

SUMMARY AND CONCLUSIONS

Although studies demonstrating improved clinical outcomes for critically ill patients managed by focused critical care echocardiography are generally lacking, there is evidence to suggest that some intermediate outcomes are improved. Furthermore, noncardiologists can learn focused critical care echocardiography and adequately interpret the information obtained. Noncardiologists can also successfully incorporate focused critical care echocardiography into advanced cardiopulmonary life support. Formal training and proctoring are important for safe application of focused critical care echocardiography in clinical practice. Further outcomes-based research is urgently needed to evaluate the efficacy of focused critical care echocardiography.

Ultrasound-based imaging in neurocritical care patients: a review of clinical applications

OBJECTIVE

To analyze the diagnostic, monitoring, and procedural applications of ultrasound (US) imaging in neurocritical care (NCC) patients.

METHOD

US imaging has been extensively validated in various subset of critically ill patients, but not specifically in the NCC population. We reviewed the clinical applications of US imaging for heart, vascular, brain, and lung evaluation and for possible procedural uses in NCC patients. Major neurosurgical books, journals, testimonials, authors' personal experience, and scientific databases were analyzed.

RESULTS

Cardiac US imaging provides accurate information at NCC arrival to stratify risk factors, including presence of atrial septal defect/patent formen ovale, abnormal ventricular function, or pericardial effusion, and to monitor cardiac anatomy and function during the NCC stay for guiding goal-directed therapy. Vascular US in NCC patients has three especially relevant indications: to screen anatomy and flow in extracranial supra-aortic arteries, to diagnose deep vein thrombosis, and to optimize the safety of central venous catheterization. Brain US has important clinical applications in the NCC, including transcranial Doppler and emerging techniques for cerebral blood flow evaluation with contrast-enhanced US imaging. Lung US, as demonstrated in other intensive care unit patients, provides accurate diagnosis of anatomical and functional abnormalities and enables diagnosis of pleural effusion, pneumothorax, lung consolidation, pulmonary abscess and interstitial-alveolar syndrome, and lung recruitment/derecruitment. US imaging can effectively guide percutaneous tracheostomy.

CONCLUSION

In conclusion, US imaging is an important diagnostic tool that provides real-time information at the bedside to stratify risk, monitor for complications, and guide invasive procedures in NCC patients.

Utility of echocardiography in hypotension in the intensive care unit

A prospective study was performed on the utility of echocardiography in diagnosing hypotension in critically ill patients. In our study, we found that transthoracic echocardiography can help physicians determine the etiology of hypotension in a significant number of patients. Transesophageal echocardiography is useful when results obtained from transthoracic echocardiography are suboptimal. Left ventricular function assessed by echocardiography can be used to predict 30-day mortality.

Core review: physician-performed ultrasound: the time has come for routine use in acute care medicine

The use of ultrasound in the acute care specialties of anesthesiology, intensive care, emergency medicine, and surgery has evolved from discrete, office-based echocardiographic examinations to the real-time or point-of-care clinical assessment and interventions. "Goal-focused" transthoracic echocardiography is a limited scope (as compared with comprehensive examination) echocardiographic examination, performed by the treating clinician in acute care medical practice, and is aimed at addressing specific clinical concerns. In the future, the practice of surface ultrasound will be integrated into the everyday clinical practice as ultrasound-assisted examination and ultrasound-guided procedures. This evolution should start at the medical student level and be reinforced throughout specialist training. The key to making ultrasound available to every physician is through education programs designed to facilitate uptake, rather than to prevent access to this technology and education by specialist craft groups. There is evidence that diagnosis is improved with ultrasound examination, yet data showing change in management and improvement in patient outcome are few and an important area for future research.

Transesophageal Echocardiography–Guided Hemodynamic Assessment and Management

Hemodynamic instability (shock) poses a major challenge in intensive care and is associated with increased mortality, morbidity, length of stay, and costs. The purpose of hemodynamic assessment and management is to detect the cause of hemodynamic instability in a given patient, provide actionable information for the physician, and thus help guide the management and resolution of hemodynamic instability. Although transesophageal echocardiography (TEE) has been the gold standard for hemodynamic assessment and management in the cardiac operating room, the invasive nature of conventional TEE has limited its use as a management tool in intensive care. Instead, one has seen a variety of indirect hemodynamic monitors used, despite now well understood limitations as described in a previous Critical Conversation in the July 2011 issue of this journal. Here we describe the use of TEE in intensive care as well as a new TEE system (the ImaCor hTEE system, ImaCor, Garden City, NY) with a miniaturized (approximately nasogastric tube sized), indwelling probe designed specifically for TEE-guided hemodynamic assessment and management in intensive care (hemodynamic TEE).

[Role of echocardiography in the hemodynamic monitorization of critical patients]

The use of echocardiography in intensive care units in shock patients allows us to measure various hemodynamic variables in an accurate and a non-invasive manner. By using echocardiography not only as a diagnostic technique but also as a tool for continuous hemodynamic monitorization, the intensivist can evaluate various aspects of shock states, such as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures, heart-lung interaction and biventricular interdependence. However, to date there has been little guidance orienting echocardiographic hemodynamic parameters in the intensive care unit, and intensivists are usually not familiar with this tool. In this review, we describe some of the most important hemodynamic parameters that can be obtained at the patient bedside with transthoracic echocardiography in critically ill patients.

[How should anesthesiologists perform ultrasound examinations? Diagnostic use of ultrasound in emergency and intensive care and medicine]

Ultrasound imaging has attained great significance as a tool for diagnostics in emergency and intensive care medicine. The major advantages of this technique are its instantaneous bedside availability and the possibility to perform repeatable examinations. These advantages are based on recent developments, such as portable ultrasound devices offering excellent imaging quality as well as a quick-start-function. Ultrasound imaging in critically ill patients is frequently performed under pressure of time depending on the current acute physical state. All standard examinations in echocardiography, vascular, abdominal and thoracic ultrasound scanning can be applied in these patients. Based on the clinical scenario the duration of examinations may vary from seconds during cardiopulmonary resuscitations to time-consuming repeated scanning. The transition from basic to subject-specific detailed examinations is flowing and has to be adjusted to local conditions. In the field of emergency and intensive care medicine the technique used is whole-body sonography. The goal is to classify the patient's present physical state and to define a targeted therapeutic approach. The characteristics of whole-body sonography are similar to the field of anesthesiology which is an interdisciplinary one. Currently, these characteristics deserve more attention in training in sonography.

Echocardiography in the Intensive Care Unit

As ultrasound technology improves and ultrasound availability increases, echocardiography utilization is growing within intensive care units. Although not replacing the often-needed comprehensive echocardiographic evaluation, limited bedside echocardiography promises to provide intensivists with enhanced diagnostic ability and improved hemodynamic understanding of individual patients. Routine and emergency echocardiography within the intensive care unit focuses on identifying and optimizing medically treatable conditions in a timely manner. Methods for such goal-directed assessments are presented.

Safety of transesophageal echocardiography

Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.

Use of transoesophageal echocardiography during the peri-operative period for trauma patients

The medical facility at Camp Bastion continues to evolve as a consequence of the increased throughput of battlefield trauma patients. There is a requirement for rapid and accurate diagnosis of haemodynamic instability and continued haemodynamic monitoring throughout the peri-operative period. Transoesophageal echocardiography (TOE) has been used for this purpose in the arena of cardiac anaesthesia since the mid 1980s. It is being introduced to other peri-operative settings where severe haemodynamic instability is expected. The old proverb: 'There are none so blind as those who cannot see' (Jeremiah 5:21) is applicable to this topic, in that TOE is proven to be a rapid, portable, safe and effective tool in the assessment of the haemodynamically unstable patient. This paper explores the application of TOE for the assessment of the major causes of haemodynamic instability in the trauma population.

Transthoracic echocardiography for the diagnosis of left ventricular thrombosis in the postoperative care unit

Introduction

Transthoracic echocardiography (TTE) is a reliable, noninvasive imaging method that is useful in the evaluation of cardiovascular thrombosis. We conducted a retrospective study of all the echocardiograms from patients in the postoperative care unit to assess the role of TTE in thrombus identification in the left ventricle.

Methods

This retrospective database evaluation included all echocardiograms during a 14-month period. The echocardiographic examination protocol included the subcostal four-chamber view, the apical four-chamber view, the apical two-chamber view and the parasternal view, along the long and short axes in both spontaneously and mechanically ventilated patients. All echocardiograms were obtained within the 48 hours immediately following surgery.

Results

In total, 160 postoperative echocardiograms were obtained from 160 patients and resulted in the detection of five cases of left ventricular thrombosis. Subgroup analysis showed that 21 and 35 of the 160 patients examined had either dilated or ischemic cardiomyopathy, respectively. In these patients, preoperative echocardiograms had been obtained recently prior to surgery and were negative for left ventricular thrombus. In three of 35 patients with ischemic cardiomyopathy and two of 21 patients with dilated cardiomyopathy, thrombus was identified in the left ventricle. The thrombi were mobile, uncalcified and pedunculated and were located in the apex of the left ventricle. In addition, no clinical consequences of the left ventricular thrombi were recorded.

Conclusions

Low-flow conditions in heart chambers due to ischemic or dilated cardiomyopathy in conjunction with the hypercoagulability caused by perioperative prothrombotic factors may lead to thrombotic events in the left ventricle.

Use of echocardiography and modalities of patient monitoring of trauma patients

PURPOSE OF REVIEW

Trauma patients require evaluation of the anatomic structure as well as the hemodynamic profile of the heart to improve effectiveness of resuscitation. They are prone to hemodynamic instability and must be monitored with various modalities to detect deterioration early. Newer, less invasive ultrasound technologies are replacing familiar 'gold standard' modalities of the past. This article reviews the indications, roles, imaging approaches, and limitations of modern echocardiography. A brief review of other ICU monitoring modalities is also presented.

RECENT FINDINGS

Echocardiography has emerged as a first-line diagnostic tool for assessment of trauma patients, especially those with hemodynamic compromise. It yields crucial information about structural damage as well as the hemodynamic profile and can be performed through either the transesophageal or transthoracic route. Quick and systematic use of echocardiography for diagnosis and management of critically injured patients may lead to improved outcomes.

SUMMARY

Echocardiography plays an important role in the trauma bay for diagnosis of thoracic injury and at the bedside in the ICU for evaluation of the hemodynamic profile.

Use of transesophageal echocardiography in burns:a retrospective review

Transesophageal echocardiography (TEE) is a useful tool in the evaluation and management of critically ill patients. However, it has not been studied in the burn population. The purpose of this review is to describe the safety and utility of TEE in the management of acute burns. This retrospective review included all acute burn inpatients who underwent TEE during a 5-year period at our regional burn center. TEE board-certified anesthesiologists performed all studies. We reviewed the chart of patients who underwent TEE, the indication for TEE, the effect of TEE on clinical management, and complications resulting from TEE. Seventeen burn patients underwent TEE during the review period. The median age was 45.4 years. Fourteen of 17 patients were men (82%). Median TBSA burn was 43.4%. Seven patients (41%) were on vasopressors or inotropic agents at the time of TEE. The main indications for TEE were hypotension and bacteremia. Findings included hypovolemia, mitral valve vegetation, pulmonary hypertension, pericardial effusion, fluid overload, right heart failure, and normal TEE. Therapeutic changes occurred after TEE in two patients; these included initiation of inotropic support and antibiotics. There were no complications identified in association with TEE. TEE is a safe procedure that serves multiple diagnostic purposes. TEE is being used to better understand the fluid status and cardiac physiology of the critically ill burn patient.

Inadequate visualization and reporting of ventricular function from transthoracic echocardiography after cardiac surgery

OBJECTIVES

The purpose of this study was to determine the incidence of and risk factors for inadequate reporting of ventricular function from transthoracic echocardiography after cardiac surgery.

DESIGN AND SETTING

A retrospective study of cardiac surgical patients at 1 university hospital.

PATIENTS

The first 300 consecutive patients who had transthoracic echocardiogram within the first 7 days after cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes for this study were inadequate visualization of the left ventricle, the right ventricle, or both ventricles. Analysis of data from 300 patients identified inadequate imaging of the left ventricle in 50 (17%) cases, inadequate imaging of the right ventricle in 112 (37%) cases, inadequate imaging of both ventricles in 37 (12%) cases, and inadequate imaging of either the left or right ventricle in 125 (42%) cases. Increasing age, earlier postoperative day, male sex, and median sternotomy were associated with inadequate imaging.

CONCLUSIONS

Transthoracic imaging is often inadequate in patients who have undergone recent cardiac surgery. Patient and surgical characteristics influence reporting of right and left ventricular function.

[Echocardiography in the Intensive Care Unit]

The echocardiography can provide important and relevant information and the critically ill patient presents a challenge for the echocardiographer: from limitations in image acquisition to interpretation in the context of rapid physiological and intervention changes. The most frequent reason for requesting an echocardiogram in the ICU is probably to assess left ventricular function. In any case, information of direct relevance for clinical management can in relationship to abnormalities of structure and function can be obtained and used to estimate pulmonary arterial and venous pressures. It can help to investigate the consequences of myocardial ischemia, valvular dysfunction and pericardial disease and detect changes characteristic of specific conditions (e.g. sepsis, pulmonary thromboembolism), although this must be interpreted in the context of each individual patient. The echocardiography also can be used to monitor the therapeutic interventions. The applications of echocardiography in the critical care setting are reviewed, with special emphasis on the assessment of cardiac physiology.

Impact of echocardiography on patient management in the intensive care unit: an audit of district general hospital practice

BACKGROUND

Echocardiography has been shown to positively impact on the management of the critically ill patient. However, many published studies have a significant bias towards inclusion of cardiothoracic patients. We present an audit of the impact of echocardiography on the management of patients in a district general hospital intensive care unit (ICU).

METHODS

We conducted a prospective audit of all echocardiograms, both transthoracic (TTE) and transoesophageal (TOE), performed on our ICU between October 1, 2005, and December 31, 2007. In addition to patient characteristics, we recorded the indication for the echocardiogram, and any change in management that occurred as a result of the study.

RESULTS

Two hundred and fifty-eight echocardiograms were performed in 217 patients, of which 224 (86.8%) were performed by intensive care consultants. One hundred and eighty-seven studies (72.4%) were TTEs and 71 (27.8%) were TOEs. TTE provided diagnostic images in 91.3% of spontaneously breathing and 84.2% of mechanically ventilated patients. Management was changed directly as a result of information provided in 51.2% of studies. Changes included fluid administration, inotrope or drug therapy, and treatment limitation.

CONCLUSIONS

Echocardiography may have a significant impact on the management of patients in the general ICU. We recommend that appropriate training in echocardiography should be incorporated into the intensive care curriculum in the UK.

Transesophageal echocardiography and noncardiac surgery

The use of transesophageal echocardiography (TEE) for monitoring during cardiac and noncardiac surgery has increased exponentially over the past few decades. TEE has evolved from a diagnostic tool to a monitoring device and a procedural adjunct. The close proximity of the TEE transducer to the heart generates high-quality images of the intracardiac structures and their spatial orientation. The use of TEE in noncardiac and critical care settings is not well studied, and the evidence of the benefits of its use in these settings is lacking. Despite the widespread availability of TEE equipment in US hospitals, less than 30% of anesthesiologists are formally trained in the use of perioperative TEE. In this review, the safety and indications of TEE are reviewed and detailed analysis of the best available evidence in this regard is presented. Landmark trials evaluating the use of TEE and its therapeutic impact in noncardiac surgical setting are critically reviewed. This article details recommendations to familiarize anesthesiologists with TEE technology to exploit it to its fullest potential to achieve better patient monitoring standards and eventually improve outcome. Training of greater numbers of anesthesiologists in TEE is needed to increase awareness of the indications and contraindications. Until relatively inexpensive TEE equipment is available, the initial cost of equipment acquisition remains a significant prohibitive factor limiting its widespread use.

Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS)

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described. Obtaining competence in ICU echocardiography may be achieved in different ways - either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level--obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.

The importance of transesophageal echocardiography in diagnosis of pericardial tamponade after cardiac surgery

BACKGROUND AND AIM OF THE STUDY

Despite the fact that there is a simple and effective treatment for pericardial tamponade (PCT), delayed diagnosis can cause serious morbidities or even mortality. In this study, we discuss the management and the diagnostic procedures of PCT.

MATERIALS AND METHODS

Sixty-two patients with suspected PCT were initially evaluated with transthoracic echocardiography (TTE) and then with transesophageal echocardiography (TEE). Forty-nine (79%) patients were chosen for surgery after TEE displayed a suspected PCT diagnosis. Patients with suspected PCT were divided into two groups: Early-phase PCT (symptoms developed within 72 hours) and late-phase PCT (symptoms developed after 72 hours).

RESULTS

Thirty-five (56%) patients were in the early phase and 27 (44%) patients were in the late phase. In 13 out of 22 (59%) cases, from both early and late phases, TTE findings showed no PCT, but TEE findings showed a positive PCT diagnosis. All 13 of the cases where TEE was positive after a negative TTE were confirmed by surgery. Overall, the PCT diagnoses in 48 out of 49 patients were confirmed during surgery.

DISCUSSION

The role of echocardiography in PCT diagnosis is shown to be extremely important in some clinical cases, such as in patients during the postoperative period after cardiac surgery. Furthermore, particularly when TTE does not provide complete imaging of the pericardial sac, TEE should be mandatory. We recommend that even patients with a negative diagnosis of PCT from TTE should undergo further evaluation with TEE.

The pulmonary artery catheter in Australasia: a survey investigating intensive care physicians' knowledge and perception of future trends in use

A survey was conducted to assess the knowledge and trends of use of the pulmonary artery catheter amongst intensive care practitioners in Australasia. A 31-item multiple choice questionnaire, identical to one previously trialled in studies in the United States and Europe, was distributed to all registered intensive care specialists and trainees working in intensive care units in Australasia. Five-hundred-and-forty-one questionnaires were distributed and 151 (27.9%) were returned, with an average mark of 82.7% +/- 9.3% and a range of 53.3 to 100%. Total score was significantly associated with years of experience in intensive care (P < 0.04), number of pulmonary artery catheters inserted (P < 0.015) and whether or not the respondent had passed the Joint Faculty of Intensive Care Medicine examination (P < 0.01). Scores were significantly higher amongst trainees (P < 0.0001) and physicians who had passed the Joint Faculty of Intensive Care Medicine examination (P < 0.0001). Overall, 44.9% of respondents indicated their use of the pulmonary artery catheter was decreasing, with 42.6% indicating their use was the same over the past five years. Sixty-one percent of respondents indicated they either agreed or strongly agreed with the statement that the use of echocardiography should supersede the use of the pulmonary artery catheter by intensive care specialists in the future. We concluded that in this study, knowledge of the pulmonary artery catheter and its use is better in Australasia than in previous studies in North America and Europe. The majority of respondents in Australasia believe that echocardiography will supersede the use of the pulmonary artery catheter in the future.