From the The Medical Center, Navicent Health (T.N., D.B.C.), Department of Surgery, Mercer University School of Medicine, Macon, GA.
J Trauma Acute Care Surg. 2019 Jul;87(1):234-239. doi: 10.1097/TA.0000000000002310.
Volume replacement strategies and resuscitation endpoints of therapy in the critical ill or injured patient continues to be a heavily debated topic despite decades of research and the ever evolving technologies that provide for alternate methods of monitoring. Hemodynamic transesophageal echocardiography (hTEE), refined for the use in the intensive care unit (ICU), allows for direct visualization of cardiac filling and function, enabling real-time guidance in the resuscitation of critically ill patients. The disposable, 17F hTEE probe can remain indwelling for up to 72 hours, providing continuous, unobstructed assessments of cardiac activity via the transgastric short axis, midesophageal four chamber, and superior vena cava views. With such, preload and contractility, ventricular size and function, and volume responsiveness can be accurately evaluated and trended for change over time. Hemodynamic transesophageal echocardiography as a monitoring modality is becoming more pervasive in ICUs on a worldwide scale, allowing for real-time visualization of resuscitation and its therapeutic effects, a better understanding of resuscitation effects on individual patients, a more rapid conclusion to patient's resuscitation needs and provides the physician more confidence and patience in guiding complex volume resuscitations.
This presentation will focus on discussing practical applications of the hTEE system and its benefits in critical care management. We will review four patients at our facility admitted to the ICU due to hemodynamic instability of varying etiologies that required volume resuscitation. With the videos, we will demonstrate how hTEE can guide patient therapy, often counter-intuitively, in the critically ill using the three basic cardiac views. Specific scenarios and hTEE videos include: (1) volume resuscitation in Acute Respiratory Distress Syndrome (ARDS), (2) volume resuscitation guided by hTEE, (3) underresuscitation in a "routine" trauma case, and (4) deescalation of therapy by weaning of high-dose vasopressors using hTEE monitoring.
Hemodynamic transesophageal echocardiography is an excellent hemodynamic monitoring modality for the intensivist and has many practical applications in the management of the critical ill or injured patients. Hemodynamic transesophageal echocardiography has demonstrated that patient's resuscitation needs are often underestimated and that a more tailored approach to volume delivery is achievable, a particular benefit in the older and more comorbid patient. Future applications of hTEE include CRRT volume management, organ donor hemodynamic optimization, and postresuscitation monitoring in trauma patient requiring massive transfusion protocol. These videos demonstrate examples of the benefits of real-time cardiac monitoring, which allowed for guided resuscitation and improved patient outcomes.
Procedures and techniques, level IV.
尽管数十年来的研究和不断发展的技术为监测提供了替代方法，但在重症或受伤患者中，容量替代策略和治疗复苏终点仍然是一个备受争议的话题。经食管超声心动图（hTEE）经过改良，可用于重症监护病房（ICU），可直接观察心脏充盈和功能，为重症患者的复苏提供实时指导。一次性使用的 17F hTEE 探头可留置长达 72 小时，通过经胃短轴、中隔四腔和上腔静脉视图提供连续、无阻碍的心脏活动评估。这样可以准确评估前负荷和收缩力、心室大小和功能以及容量反应性，并随时间变化进行趋势分析。经食管超声心动图作为一种监测方式，在全球范围内的 ICU 中越来越普及，可实时观察复苏及其治疗效果，更好地了解复苏对个体患者的影响，更快地确定患者的复苏需求，并为医生提供更多信心和耐心，指导复杂的容量复苏。
本演讲将重点讨论 hTEE 系统的实际应用及其在重症监护管理中的益处。我们将回顾我们机构因不同病因导致血流动力学不稳定而入住 ICU 的四名患者，他们需要容量复苏。通过视频，我们将展示 hTEE 如何使用三个基本的心脏视图指导患者治疗，这在重症患者中往往是反直觉的。具体场景和 hTEE 视频包括：（1）急性呼吸窘迫综合征（ARDS）的容量复苏，（2）hTEE 指导下的容量复苏，（3）“常规”创伤病例中的复苏不足，以及（4）使用 hTEE 监测逐渐减少高剂量血管加压素的治疗。
经食管超声心动图是重症监护医师的一种优秀的血流动力学监测方式，在重症或受伤患者的管理中有许多实际应用。经食管超声心动图表明，患者的复苏需求往往被低估，并且可以实现更针对性的容量输送方法，这对老年和合并症较多的患者尤其有益。hTEE 的未来应用包括 CRRT 容量管理、器官捐献者血流动力学优化以及需要大量输血方案的创伤患者的复苏后监测。这些视频展示了实时心脏监测的益处示例，这使得指导复苏和改善患者预后成为可能。
程序和技术，IV 级。
