Hüttemann E
Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany.
Minerva Anestesiol. 2006 Nov;72(11):891-913.
Echocardiography has evolved to become one of the most versatile modalities for diagnosing and guiding treatment of critically ill patients. Both transthoracic (TTE) and transesophageal echocardiography (TEE) provide real-time bedside information about a variety of structural and functional abnormalities of the heart as well as contractility, filling status and cardiac output, rendering it the method of choice for the assessment of cardiac function in the intensive care unit (ICU). Both approaches have its benefits and limitations. Although TTE remains the approach of choice, TEE has been shown to be of additional value in many instances in critically ill patients due to its ability to provide excellent visualisation of cardiac structures, its impact on patient management, and its low complication rate (2.6%). The present status of TEE in adult critical care is reviewed with special emphasis on its role as a diagnostic tool in several clinical scenarios, underlining its effects on clinical decision making but also as a monitoring adjunct. Conditions and settings in which TEE provides the most definitive diagnosis in the critically ill and injured are hemodynamically unstable patients with suboptimal TTE images or if mechanically ventilated, patients with suspected aortic dissection or aortic injury and other conditions in which TEE is superior to TTE (such as suspected endocarditis, cardiac or aortic source of emboli. The diagnostic, therapeutic and surgical impact on patient management in critically ill patients ranged from 44% to 99% (weighted mean 67.2%), 10% to 69% (weighted mean 36%), and 2% to 29% (weighted mean 14.1%), respectively, depending on patients and type of ICU. Since echocardiography provides different information than other devices for hemodynamic monitoring such as the pulmonary artery catheter the methods are therefore not competitive but rather complementary. The present body of evidence supporting the use of TEE in critically ill patients lacks prospective, randomized controlled studies focusing on end-points like cost-effectiveness, morbidity or mortality. However, present evidence as well as experience, points to the significant benefits which may be gained by the availability of echocardiography and especially TEE in ICUs, as well the necessity for a training of intensive care physicians.
超声心动图已发展成为诊断和指导重症患者治疗的最通用方法之一。经胸超声心动图（TTE）和经食管超声心动图（TEE）均可在床边实时提供有关心脏各种结构和功能异常以及心肌收缩力、充盈状态和心输出量的信息，使其成为重症监护病房（ICU）评估心脏功能的首选方法。这两种方法都有其优点和局限性。尽管TTE仍然是首选方法，但由于TEE能够提供心脏结构的出色可视化、对患者管理的影响以及较低的并发症发生率（2.6%），在许多重症患者中已显示出其额外价值。本文综述了TEE在成人重症监护中的现状，特别强调其在几种临床情况下作为诊断工具的作用，强调其对临床决策的影响以及作为监测辅助手段的作用。在重症和受伤患者中，TEE能提供最明确诊断的情况和场景包括血流动力学不稳定且TTE图像欠佳的患者，或机械通气的患者、疑似主动脉夹层或主动脉损伤的患者以及其他TEE优于TTE的情况（如疑似心内膜炎、心脏或主动脉栓子来源）。TEE对重症患者管理的诊断、治疗和手术影响分别为44%至99%（加权平均值67.2%）、10%至69%（加权平均值36%）和2%至29%（加权平均值14.1%），具体取决于患者和ICU类型。由于超声心动图提供的信息与其他血流动力学监测设备（如肺动脉导管）不同，因此这些方法并非相互竞争，而是相互补充。目前支持在重症患者中使用TEE的证据缺乏专注于成本效益、发病率或死亡率等终点的前瞻性、随机对照研究。然而，目前的证据以及经验表明，ICU中具备超声心动图尤其是TEE可能会带来显著益处，同时也表明重症监护医生进行培训的必要性。
