Original Article
The Feasibility and Impact of Routine Combined Limited Transthoracic Echocardiography and Lung Ultrasound on Diagnosis and Management of Patients Admitted to ICU: A Prospective Observational Study

https://doi.org/10.1053/j.jvca.2017.08.026Get rights and content

Objectives

Limited transthoracic echocardiography (TTE) and lung ultrasound increasingly is performed in the intensive care unit (ICU), though used in a goal-directed rather than routine manner.

Design

Prospective observational study.

Settings

Tertiary ICU.

Participants

Ninety-three critically ill participants within 24 hours of admission to ICU.

Methods

A treating intensivist documented a clinical diagnosis and management plan before and after combined limited TTE and lung ultrasound. Ultrasound was performed by an independent intensivist and checked for accuracy offline by a second reviewer.

Results

Ultrasound images were interpretable in 99%, with good interobserver agreement. The hemodynamic diagnosis was altered in 66% of participants, including new (14%) or altered (25%) abnormal states or exclusion of clinically diagnosed abnormal state (27%). Valve pathology of at least moderate severity was diagnosed for mitral regurgitation (7%), aortic stenosis (1%), aortic stenosis and mitral regurgitation (1%), tricuspid regurgitation (3%), and 1 case of mitral regurgitation was excluded. Lung pathology diagnosis was changed in 58% of participants including consolidation (13%), interstitial syndrome (4%), and pleural effusion (23%), and exclusion of clinically diagnosed consolidation (6%), interstitial syndrome (3%), and pleural effusion (9%). Management changed in 65% of participants including increased (12%) or decreased (23%) fluid therapy, initiation (10%), changing (6%) or cessation (9%) of inotropic, vasoactive or diuretic drugs, non-invasive ventilation (3%), and pleural drainage (2%).

Conclusion

Routine screening of patients with combined limited TTE and lung ultrasound on admission to ICU is feasible and frequently alters diagnosis and management.

Section snippets

Methods

This prospective observational study was conducted with approval from the Human Research and Ethics Committee at Peninsula Health (HREC/12/PH/34) and written consent was obtained from all participants or from next of kin.

The study site was a University tertiary referral hospital medical and surgical ICU at Frankston Hospital in Australia. This ICU does not receive cardiothoracic surgery, trauma, spinal injury, or burns patients. Participants were screened for eligibility when the investigating

Results

Ninety-nine participants were screened and 93 were recruited between August 2012 and December 2013. Six participants were not included due to inability to obtain consent3 or very poor patient prognosis where palliative management was already decided.3 The participant characteristics are shown in Table 1. The most common admission diagnoses were sepsis (39%) and out-of-hospital cardiac arrest (14%). Limited TTE was performed on all participants, but imaging was inadequate to assess the

Discussion

The authors have shown a “proof of concept” that adding routinely performed combined limited TTE and lung ultrasound as an adjunct to clinical evaluation led to a high incidence of change in diagnosis and management. Feasibility was demonstrated by interpretable images being obtained in the majority of participants and good inter-observer agreement. Importantly, very few diagnostic errors in the ultrasound examinations were detected by an independent observer.

Changes in diagnosis occurred in 2

Conclusion

Routine screening of patients with combined limited TTE and lung ultrasound on admission to intensive care is feasible and frequently alters diagnosis and management.

Acknowledgments

We are grateful for the assistance of many staff at Frankston Hospital who helped in this study. We also thank Sandy Clarke, PhD (statistical consulting, The University of Melbourne) who assisted with the statistical analysis.

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