Background:
There is increasing concern regarding the value and cost of using transthoracic echocardiograms (TTEs) to assess volume status in critically ill patients. Using clinical and echocardiographic parameters, we assessed whether TTE changed clinical management of patients in the intensive care unit (ICU).
Methods:
Using the Dartmouth-Hitchcock echocardiography database, we identified 218 ICU patients whose TTE was performed to assess volume status from 4/1/11 to 3/31/14. The following TTE parameters were assessed: left ventricular ejection fraction (LVEF), diastolic function parameters, left atrial size, significant valvular disease, pericardial effusion, inferior vena cava (IVC) size and collapsibility, right ventricular (RV) function and pulmonary artery systolic pressure. In addition, clinical data were collected from review of the medical record including: age, vitals, intubation status, labs, and management change after TTE results became available.
Results:
Of the 218 patients, cardiac tamponade was present in 6 patients and right heart strain suggestive of pulmonary embolus was present in 2 patients. Of the remaining 210 patients, TTE did not affect clinical management in 186 (88.6%), led to administration of diuretics in 8 (3.8%), and intravenous fluids in 16 (7.6%). Of the 218 total patients, 123 (56.4%) were intubated. Compared to non-intubated patients, intubated patients were more likely to have elevated right atrial pressure, RV dysfunction, IVC size and collapsibility index (p<0.05). There was no difference in the severity of pulmonary hypertension, LVEF, or indices of elevated left ventricular filling pressure (p=NS). Although the echo parameters were different, the decision by physicians to administer intravenous fluids or diuretics was similar for both groups (p=NS).
Conclusions:
Transthoracic echocardiogram is commonly ordered to assess volume status in the ICU. The use of echocardiographic parameters to assess volume status did not change clinical management in majority of patients and should be used with caution in this cohort. Continued investigation to identify the best modality to assess volume status in critically ill patients is warranted.
Vanishing Left Ventricular Thrombi in Severe Aortic Stenosis with Dilated Cardiomyopathy
