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Impact of Point-of-Care Echocardiography in the Management of Septic Shock Guided by Pulse Contour Cardiac Monitoring FREE TO VIEW

Philip Svigals; John Huggins; Carlos Kummerfeldt; Jennings Nestor; Kenneth Walters; Nicholas Pastis; Peter Doelken
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Medical University of South Carolina, Charleston, SC

Chest. 2014;146(4_MeetingAbstracts):574A. doi:10.1378/chest.1995021
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SESSION TITLE: Diagnostic Procedures and Interventions Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PM

PURPOSE: Point-of-care echocardiography (POCE) is an emerging tool for the intensivist in the management of critically-ill patients. However, the use of this modality requires dedicated training and expertise. Pulse contour cardiac monitors (PCCM) are routinely used in the management of shock in our institution with little validation on their reliability in the setting of shock. Our specific aims were: 1) to determine a correlation of stroke volume (SV) and cardiac output (CO) as measured by POCE compared to (PCCM) and 2) to determine if POCE changed diagnosis and management of shock.

METHODS: POCE was performed on 10 consecutive patients admitted to the Medical Intensive Care Unit with a clinical diagnosis of septic shock, requiring vasopressors and mechanical ventilation. PCCM was initiated to help guide their management. All POCE examinations were performed with a Sonosite© M-turbo equipped with a 5-1MHz probe (Sonosite, Bothel, WA). SV calculated by POCE was obtained by measuring the left ventricular outflow tract (LVOT) cross-surface area of the LVOT multiplied by the velocity time integral of the LVOT as measured by pulse-wave Doppler from a 5-chamber apical view. All POCE examinations were performed in a blinded fashion. Significant mitral and aortic valvular diseases were excluded.

RESULTS: Eighteen POCE examinations were performed on the 10 patients. Two POCE examinations were conducted when vasopressors were off and therefore excluded from analysis. Correlation analysis comparing SV/CO derived from POCE with PCCM was not significant (p=0.78). In four cases, the cause of shock was re-classified by POCE: two had pure cardiogenic failure (one due to viral myocarditis, the other due to ischemia), and two, had severe right ventricular (RV) failure that was noted in the setting of acute respiratory distress syndrome (ARDS) and septic shock. Medical decision-making was modified in all four patients.

CONCLUSIONS: POCE re-classified the cause of shock in 20%, and in another 20%, identified the presence of severe RV failure complicating ARDS and septic shock not otherwise known. POCE lead to a change in the clinical management of this cohort in 40% of the patients.

CLINICAL IMPLICATIONS: POCE is the only noninvasive modality which allows one to diagnose RV failure, a complication that occurs frequently in ARDS and sepsis. Rapid identification of RV failure in the criticallty-ill if treated promptly may improve survival, since it is known that RV failure is an independent predictor of mortality in ARDS and sepsis.

DISCLOSURE: The following authors have nothing to disclose: Philip Svigals, John Huggins, Carlos Kummerfeldt, Jennings Nestor, Kenneth Walters, Nicholas Pastis, Peter Doelken

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