Echocardiography (echo) is often requested to assist in the management of hemodynamically unstable patients in the medical intensive care unit (MICU).Little is known about the actual impact of echo on clinical decision making and therapeutic choices. The objective of this study is to determine the impact of transthoracic echo (TTE) on management decisions and treatment strategies.
We retrospectively reviewed 100 consecutive patients from 30 June 2000 to 1 July 2001. Data included demographics, admission diagnosis, indication for echo,findings,length of stay and major therapeutic interventions performed within 48 hours of the echo. The echo findings were classified as:normal, severe valvular insufficiency or stenosis,valvular vegetations /thrombus, hemodynamic instability sec to pericardial effusion, right ventricular pressure >5O mm hg, left ventricular ejection fraction( EF)< 40%,limited study /poorly visualized, cardiomyopathy, aortic dissection, others. Multiple findings on the echo were often noted. We determined whether a change in treatment modality or diagnostic intervention occurred on the basis of the echo findings.
The mean age was 70±13 years; 60% were females. 79% underwent echo within 48 hours of admission to the ICU. Vague/undescribable/unclear/none changes in clinical care attributable to echo findings occurred in 43% of patients. See Table 1
Indication for EchoAssessment of LV function47%Assessment of wall motion abnormalities15%Assessment of PA pressures8%Arrhythmias8%Pulmonary embolism5%Shock/ hypotension5%Assessment of volume status5%Hypoxia4%Cardiomyopathy1%To r/o patent foramen ovale1%Valve thrombus1%, 2
Echo FindingsNormal study50%Hypokinesia/akinesia-EF<40%19%Poorly visualized/limitedstudy16%Right ventricular pressure >50mm Hg9%Significant valvular heart disease5%Low cardiac volume state1%, 3
Interventions within 48 hours-57%Further consults26%Interventional procedure-Swan Ganz catheters, central venous catheters, dialysis catheters25%Mechanical ventilation8%Radiological procedures including CT Scan, MRI,etc8%IV fluids boluses5%Fiberoptic bronchoscopy4%Anticoagulation4%Antibiotics(adding/delete)2%Vasoactive drugs (adding/delete)2%Diuretics(add/delete)2%Coronary angiogram2%CABG1%.CONCLUSIONS: The utility of TTE to influence treatment decisions is reportedly high in the critically ill population. In our experience this impact may be less than expected in the MICU. A definitive attributable change in treatment strategy occurs in only a small percentage of patients. TTE oftens confirms clinical impressions and infrequently results in a change in management or prompts additional investigations in a MICU patient population.
Directed clinical questions and systematic decision making in the use of echo may increase its usefulness in the MICU. Specifying indications for and clinical questions to be answered by echo may assist the echocardiographer to optimize clinically important information.
J. Chandrasekhar, None.