October 16, 2019

Miniaturised TOE probe to enhance early management of shocked patient?

Could early and close haemodynamic TEE assessment with a disposable miniature echocardiography probe reduce time to resolution of hemodynamic instability for ICU patients admitted with circulatory shock?

 

Circulatory shock is burdened by poor outcome, where treatment and management keep being challenging; close haemodynamic monitoring to enhance early resolution of shock may improve outcomes.

This trial compares usual care to a haemodynamic TEE assessment (hTEE) with a disposable miniature echocardiography probe in order to mainly analyse time to resolution of haemodynamic instability in a single ICU centre study including patient with circulatory shock.

Authors included adult patients requiring unplanned admission in ICU, with haemodynamic shock of any cause, defined according to sepsis guidelines. 550 patients of 8812 ICU admission were allocated and organised into two groups, further stratified into two other groups:

  • hTEE group (271 patients): hTEE assessment at inclusion, followed by evaluation when new organ system deterioration occurred or at least every four hours (hTEE protocoled monitoring – hTEEPM) or at least every eight hours (hTEE standard monitoring – hTEESM)
  • control group (274 patients): haemodynamic monitoring at discretion of treating specialist, when new organ system deterioration occurred or at least every four hours (control protocoled monitoring – ControlPM) or at least every eight hours (control standard monitoring – ControlSM)

The time to resolution of haemodynamic instability did not differ between hTEE group and control patient (HR 1.20, 95%CI 0.98 – 1.46, p= 0.067). In the per-protocol analysis (249 vs 250 patients), the primary outcome (time to resolution of haemodynamic instability) was shorter in the hTEE group than in the control group (HR 1.24, p=0.045). The per-protocol analysis at 3 days indicated earlier resolution of shock in the hTEE patients (HR 1.3, p = 0.018).

Secondary analysis of time to resolution of haemodynamic instability by monitoring frequency (at least every four hours vs. eight hours) showed no significant differences (HR 0.96, p = 1.16 at 6 days, HR 0.98, p = 0.88 at 3 days).

Time to death and 28-day mortality did not differ between two groups. Length of stay in ICU and in hospital, duration of mechanical ventilation or renal replacement therapy and volume administration during first 72 hours did not diverge between the groups.

 

STUDY STRENGTHS & LIMITATIONS
  1. The trial design and setting were well-made and described. This made the trial interesting and statistically-powered enough.
  2. This study enrols a high number of patients, especially for a study using hTEE and it is completely applied in the clinical reality of an ICU. The echocardiographic windows have been well clarified, as well as the applied measurements (better described in the Supplementary Material).
  3. The use of hTEE during early phase of shock can help in the decision-making, especially for volume assessment and ventricular dysfunction evaluation. These parameters should not be understood as isolated, but inserted in the global clinical context and interpret with other standard parameters.
  4. Shock pathophysiology, especially septic shock, is not only dependent on volume status, but also largely on vasoplegia, on which the hTEE measurement has no influence or possibility of measurement. Therefore, it is not surprising that hTEE shows no differences in outcomes that have been taken into account.
  5. This hTEE tool is only a none reusable mono planar 2D echography probe, the size of which is similar to a small nasogastric tube, with no Doppler function. Miniaturisation of Oesophageal Doppler, +/- Echo signal may be the next generation of device to offer continuous monitoring of patients with haemodynamic instability.

 

TAKE HOME MESSAGE
  • There is currently no evidence that the use of hTEE monitoring for up to 72 hours in the early phase of septic shock influenced the resolution of haemodynamic instability at 6 and 28 days.
  • Septic shock is an extremely complex pathophysiological disease, which requires the simultaneous analysis of filling status, of global cardiac function and vasoplegia. The use of hTEE can be useful in in the analysis of the first two elements, even if the complete analysis that takes into consideration the third element, vasoplegia, has not yet been developed.
  • Further multicentre trials will be necessary to confirm results of this first large single-centre trial about early shock resolution with hTEE analysis.
  • Conventional point of care echocardiography is clearly a diagnostic tool, when hTEE may facilitate close and continuous monitoring and assessment of response to treatment.

 

This article review was prepared and submitted by Paul Abraham (Head of Clinic, Hospices Civils de Lyon and Research Associate of the Geneva Haemodynamic Research Group)and Samuele Ceruti (Department of Intensive Care Unit, Ospedale Regionale di Bellinzona, Via Ospedale 12, 6500 Bellinzona, Switzerland) on behalf of the ESICM Journal Club.

 

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REFERENCES

1) Rhodes A et al., Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377

2) Cecconi M et al., Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med (2014) 40:1795–1815

3) Vincent JL, De Backer D., Circulatory Shock. N Engl J Med 2013;369:1726-34.

4) Kumar et al., Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:1589–1596

5) Ince C et al., Second consensus on the assessment of sublingual microcirculation in critically ill patients: results from a task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2018 Mar;44(3):281-299

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