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1、Critical CareCritical Care Transesophageal echocardiography as a routine tool in hemodynamically unstableTransesophageal echocardiography as a routine tool in hemodynamically unstablepatients in the surgical ICUpatients in the surgical ICU-Manuscript Draft- Manuscript Number:Manuscript Number:Full T
2、itle:Full Title:Transesophageal echocardiography as a routine tool in hemodynamically unstablepatients in the surgical ICUArticle Type:Article Type:ResearchFunding Information:Funding Information:Guangdong Science and TechnologyPlanning Project(2017B 020247002)Dr. Juan ChenWu Jieping Medical Foundat
3、ion(320.6750.18037)Dr. Xiang SiWu Jieping Medical Foundation(320.6750.18068)Mr. Xiangdong GuanAbstract:Abstract:Background: Transesophageal echocardiography (TEE) performed by intensivists isincreasingly used in critically ill patients. However, TEE is usually a supplement totransthoracic echocardio
4、graphy (TTE) instead of as a routine monitoring tool. Theclinical value of using TEE as a routine monitoring tool in hemodynamically unstablepatients in the ICU remains largely unknown. The goal of this study was to evaluate thediagnostic and therapeutic uses of TEE as a routine tool in hemodynamica
5、lly unstablepatients on mechanical ventilation.Methods: A prospective observational study was conducted. A total of 70 consecutivepatients were enrolled from December 2016 to February 2018. TEE was routinelyperformed after TTE, and the results of both TTE and TEE were immediately disclosedto the pri
6、mary physician, who reported any resulting changes in management. Theresults of each TEE examination were compared with the clinical findings and TTEdata. TEE examinations were classified as follows: group 1, TEE confirmed the initialTTE diagnosis and therapy; group 2, TEE revealed a new diagnosis b
7、ut did not resultin a change in therapy compared with TTE; group 3, TEE revealed a new diagnosisrequiring a change in therapy; group 4, TEE determined the diagnosis and therapybecause TTE failed; and group 5, TEE failed to determined the diagnosis and therapy.Results: The characteristics of the rout
8、ine TEE examination groups were as following:group 1, n = 26 (37.1%); group 2, n = 11 (15.7%); group 3, n = 23 (32.9%); group 4, n=8 (11.4%); and group 5, n= 2 (2.8%). TEE yielded better quality images with more goodviews (81.3% vs. 29.8%) and less poor views (5.4% vs. 44%) than TTE (p =0.000).Forty
9、-two (60%) of 70 TTE examinations supplied inadequate information comparedwith 2 (3%) of 70 TEE examinations (p =0.000). Routine TEE examination providedcritical therapeutic information that was not obtained by TTE in 31 patients (44.3%, p=0.000)Conclusion: Our study showed that routine TEE examinat
10、ions are essential forhemodynamically unstable patients and have diagnostic and therapeutic benefits. TEEshould be performed for routine monitoring for this specific application.Key word: transesophageal echocardiography; hemodynamic; shockCorresponding Author:Corresponding Author:Xiangdong Guan, M.
11、D.Sun Yat-sen University First Affiliated HospitalCHINACorresponding Author SecondaryCorresponding Author SecondaryInformation:Information:Corresponding Authors Institution:Corresponding Authors Institution:Sun Yat-sen University First Affiliated HospitalCorresponding Authors SecondaryCorresponding
12、Authors SecondaryInstitution:Institution:Powered by Editorial Manager and ProduXion Manager from Aries Systems CorporationFirst Author:First Author:Xiang SiFirst Author Secondary Information:First Author Secondary Information:Order of Authors:Order of Authors:Xiang SiJie MaJianfeng WuYao NieDaiyin C
13、aoLingyun ZuoHailin XuMingying ChenJuan ChenZimeng LiuYongjun LiuXiangdong Guan, M.D.Order of Authors Secondary Information:Order of Authors Secondary Information:Additional Information:Additional Information:QuestionQuestionResponseResponseIs this study a clinicaltrial?A clinical trial is definedby
14、 the World Health Organisation as anyresearch study that prospectively assignshuman participants or groups of humansto one or more health-relatedinterventions to evaluate the effects onhealth outcomes.NoPowered by Editorial Manager and ProduXion Manager from Aries Systems CorporationTransesophageal
15、echocardiography as a routine tool in hemodynamically unstable patients in the surgical ICU Contributors 1. Xiang Si1* Email: james_ 2. Jie Ma 2* Email:jiema_ 3. Jian-feng Wu1* Email: 4. Yao Nie1 Email: 5. Dai-yin Cao3 Email: 6. Ling-yun Zuo1. Email: 7. Hai-lin Xu4 Email: 8. Min-ying Chen1 Email: 9.
16、 Juan Chen1 Email: 10. Zi-meng Liu1 Email: 11. Yong-jun Liu1 Email: 12. Xiang-dong Guan1,# Email: 1 Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China 2 Department of Critical Care Medicine, Jiangmen Central Hospital, Jiangmen, Guangdong 5
17、29030, China 3 Department of Critical care medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong510655 , China 4. Transplantation department，The second affiliated hospital of Guangzhou medical university，Guangzhou, China * Xiang Si, Jie Ma and Jian-feng Wu contribut
18、ed equally to this work and should be considered co-first author. # Corresponding Author: Prof. Xiang-dong Guan. Department of SICU, The First Affiliated Hospital, Sun Yat-Sen University. Address: 58 Zhongshan NO.2 road, Guangzhou, Guangdong510080, China. Tel: (8620)87331008, Fax: (8620)87331008, Em
19、ail: ManuscriptClick here to access/download;Manuscript;4-3.manuscript_TEE as_a_routine_tool.docClick here to view linked References 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
20、 60 61 62 63 64 65 Background: Transesophageal echocardiography (TEE) performed by intensivists is increasingly used in critically ill patients. However, TEE is usually a supplement to transthoracic echocardiography (TTE) instead of as a routine monitoring tool. The clinical value of using TEE as a
21、routine monitoring tool in hemodynamically unstable patients in the ICU remains largely unknown. The goal of this study was to evaluate the diagnostic and therapeutic uses of TEE as a routine tool in hemodynamically unstable patients on mechanical ventilation. Methods: A prospective observational st
22、udy was conducted. A total of 70 consecutive patients were enrolled from December 2016 to February 2018. TEE was routinely performed after TTE, and the results of both TTE and TEE were immediately disclosed to the primary physician, who reported any resulting changes in management. The results of ea
23、ch TEE examination were compared with the clinical findings and TTE data. TEE examinations were classified as follows: group 1, TEE confirmed the initial TTE diagnosis and therapy; group 2, TEE revealed a new diagnosis but did not result in a change in therapy compared with TTE; group 3, TEE reveale
24、d a new diagnosis requiring a change in therapy; group 4, TEE determined the diagnosis and therapy because TTE failed; and group 5, TEE failed to determined the diagnosis and therapy. Results: The characteristics of the routine TEE examination groups were as following: group 1, n = 26 (37.1%); group
25、 2, n = 11 (15.7%); group 3, n = 23 (32.9%); group 4, n= 8 (11.4%); and group 5, n= 2 (2.8%). TEE yielded better quality images with more good views (81.3% vs. 29.8%) and less poor views (5.4% vs. 44%) than TTE (p =0.000). Forty-two (60%) of 70 TTE examinations supplied inadequate information compar
26、ed with 2 (3%) of 70 TEE examinations (p =0.000). Routine TEE examination provided critical therapeutic information that was not obtained by TTE in 31 patients (44.3%, p =0.000) Conclusion: Our study showed that routine TEE examinations are essential for hemodynamically unstable patients and have di
27、agnostic and therapeutic benefits. TEE should be performed for routine monitoring for this specific application. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 K
28、ey word: transesophageal; transthoracic; echocardiography; hemodynamic; shock Patients with hemodynamic instability are universally observed in ICUs (Intensive Care Unit). Over one-third of critically ill patients experience hypotension or shock1, and the ratio can be as high as one-half in patients
29、 with organ dysfunction2. However, only one-third of patients live through these serious attacks3. Furthermore, common examinations used in the clinic do not provide sufficient information in life-threatening situations. Therefore, it is imperative to find a way to obtain valuable information immedi
30、ately at the patients bedside. Echocardiography is a useful procedure that simultaneously yields morphologic and hemodynamic information. Transthoracic echocardiography (TTE) has proven to be of great value in the critical care setting because of its portability, widespread availability, and instant
31、aneous diagnostic capability4. However, TTE requires a good acoustic window to allow accurate analysis. Unfortunately, numerous restrictions on the imaging ability of TTE, particularly mechanical ventilation with positive end-expiratory pressure (PEEP), are commonly present in patients in the ICU. L
32、ess hampered by these limitations, transesophageal echocardiography (TEE) overcomes these problems and yields better quality images because the position of the probe is closer to the posterior aspect of the heart5, 6. Early research has demonstrated the feasibility of critical care TEE, as comfort a
33、nd facility with TTE has been steadily actualized across a large number of providers7-9, and there is now renewed and expanding interest in TEE at many centers. A recent study10from the U.S. performed a descriptive observation in a medical ICU and found that advanced TEE could confirm the original d
34、iagnosis in more than 70% of studies and identify novel findings in approximately 30% of studies that led to changes in clinical decisions. However, in previous studies, the indication for TEE was when TTE yielded inadequate images or the clinical problems could not be solved by TTE. TEE was used as
35、 a supplement to TTE instead of as a routine monitoring tool. The clinical value of TEE as a routine monitoring tool in hemodynamically unstable patients in the ICU remains largely unknown. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
36、 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 We designed this study to prospectively evaluate the diagnostic and therapeutic value of routine TEE in critically ill patients admitted to a surgical ICU compared with TTE by analyzing the major clinical conditions of ICU p
37、atients, namely, hemodynamic instability and mechanical ventilation. Methods 1. Patients This is a prospective observation that included consecutive ventilated patients with hemodynamic instability in a surgical ICU at a tertiary teaching hospital (Guangzhou, China) from December 2016 to February 20
38、18. Hemodynamic instability was defined as a systolic arterial blood pressure less than 90 mmHg or the need for vasopressors (norepinephrine at a dosage of more than 0.1 g kg 1 min 1) to maintain a systolic blood pressure more than 90 mmHg11. The exclusion criteria included unrepaired tracheoesophag
39、eal fistula, history of prior esophageal surgery, esophageal obstruction or stricture, esophageal varix or diverticulum, gastric or esophageal bleeding, oropharyngeal pathology, and severe coagulopathy. The Medical Ethics Committee of the First Affiliated Hospital of Sun Yat-sen University approved
40、the protocol (NO.2015-120). All patients or their families signed consent forms to participate in this study. 2. Echocardiography protocol Echocardiographic examinations were performed using commercially available ultrasound scanners (M-Turbo, SonoSite). A standard 2.5-MHz ultrasound transducer was
41、used for the transthoracic studies, and a single plane 5-MHz transesophageal probe was used for the transesophageal examinations. Both TTE and TEE were performed in the supine position. If possible, patients were placed in the partial left decubitus position, especially when image acquisition failed
42、. Unless the patients were 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 previously sedated, midazolam or propofol was administered intravenously before introdu
43、ction of the TEE probe. A transesophageal endoscope was introduced blindly by simply directing the tip into the posterior part of the pharynx, maintaining a midline position and gently allowing the transducer to flex passively. We never had to deflate the cuff of the endotracheal tube or introduce t
44、he transducer under direct vision by direct laryngoscopy. The nasogastric/orogastric tube was removed if it appeared to degrade the TEE image. No antimicrobial prophylaxis was administered. Throughout the examination, electrocardiography (ECG), blood pressure, heart rate, and oxygen saturation were
45、monitored. All enrolled patients underwent TTE and TEE examinations in sequence performed by the same investigator (X.S) who had received advanced training. Images and video loops from both examinations were stored and disclosed to two different critical care attending physicians. TTE was performed
46、first, with five major views described previously12, including parasternal long-axis and short-axis views, apical four-chamber views, a subxiphoid four-chamber view and a subxiphoid inferior vena cava view. The physicians were asked to independently provide an initial diagnosis and therapy based on
47、the TTE information, and a consensus had to be reached between the two physicians if there was disagreement. Then, TEE was routinely performed with the intent of obtaining a set of twenty views according to the recommendations of a consensus statement by the American Society of Echocardiography (ASE
48、) and the Society of Cardiovascular Anesthesiologists (SCA)13. The physicians then independently reevaluated the diagnosis and therapy in light of the TEE findings. Whether or not TEE changed the course of the current diagnosis or therapy compared with TTE was noted. This finding was further classif
49、ied into five categories: group 1, TEE confirmed the initial TTE diagnosis and therapy; group 2, TEE revealed a new diagnosis but did not result in a change in therapy compared with TTE; group 3, TEE revealed a new diagnosis requiring a change in therapy; group 4, TEE determined the diagnosis and th
50、erapeutic decisions because TTE failed; and group 5, TEE failed to determine the diagnosis and therapy. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 A consensu