Surgeon-Performed Hemodynamic Transesophageal Echocardiography in the Burn Intensive Care Unit

Abstract

The use of transesophageal echocardiography (TEE) for resuscitation after burn injury has been reported in small case studies. Conventional TEE is invasive and often requires a subspecialist with a high level of training. The authors report a series of surgeon-performed hemodynamic TEE with an indwelling, less bulky, user-friendly probe. Records of patients treated in a regional burn center who underwent hemodynamic TEE between October 1, 2012 and May 30, 2014 were reviewed. The clinical course of each patient was recorded. All bedside interpretations were retrospectively reviewed for accuracy by a cardiac anesthesiologist. Eleven patients were included in the study. Median age was 68.5 years (interquartile range, 49.5-79.5). Median burn size was 37% TBSA (interquartile range: 16.3-53%). Seven patients were male, and four suffered inhalation injury. The operator's interpretation matched that of the echocardiography technician and cardiac anesthesiologist in all instances. No complications occurred from probe placement. Four patients underwent hemodynamic TEE to determine volume status during resuscitation. Changes in volume status on echocardiography preceded the eventual changes in urine output and vital signs for one patient. Hemodynamic TEE diagnosed cardiogenic shock and was used to titrate inotropes and vasopressors in seven elderly patients. Hemodynamic TEE is a useful adjunct to manage the burn patient who deviates off the expected course, especially if there is a question of cardiac function or volume status. It is less invasive and can be accurately performed by surgical intensivists when transthoracic echo windows are limited. The role of echocardiography in optimizing routine burn resuscitations needs to be further studied.

Is There a Role for Transesophageal Echocardiography in the Perioperative Trauma Patient?

“…Critically ill burned patients are a particular subset of acute trauma patients that pose unique clinical challenges in resuscitation and fluid management due to translocations in volume distribution and fluid shifts resulting in severe shock during the acute phase [ 29 ]. Several resuscitation strategies based on mathematical models that consider a patient’s weight and burn size have been suggested to determine the amount of fluid required for adequate volume resuscitation although there is still debate on its standardization [ 30 ]. Additionally, severe burn patients may present with myocardial dysfunction (both systolic and diastolic) [ 31 , 32 ] and have a higher risk of infections, sepsis, and infective endocarditis.…”

State of the Art: An Update on Adult Burn Resuscitation

“…Advanced hemodynamic monitoring is an expanding field of critical care of which some technologies have been studied in burn shock and some have not. Advanced hemodynamic monitoring generally includes modalities such as pulmonary artery catheterization, transpulmonary thermodilution (LiDCO, PiCCO), pulse-contour analysis of the arterial waveform, and echocardiographic evaluation [64]. Two meta-analyses have evaluated mortality with hemodynamic monitoring compared to UOP, and did not demonstrate a conclusive decrease in mortality [56,65].…”

“…Cardiac output measurement by ultrasonography may provide additional assessment of preload status, though transthoracic echocardiography can be very challenging in burn-injured patients due to burns to the chest that interfere with image acquisition. Hemodynamic transesophageal echocardiography (hTEE) provides a low-risk means to monitor cardiac preload and contractility real-time throughout the resuscitative period [64].…”

Transesophageal Echocardiographic Measurements of the Superior Vena Cava for Predicting Fluid Responsiveness in Patients Undergoing Invasive Positive Pressure Ventilation

“…6 Several studies indicated that the SVC diameter is easily measured with transesophageal echocardiography (TEE) during surgery. [6][7][8] Our study aimed to estimate the effectiveness of the SVC diameter and variation in predicting fluid responsiveness in patients undergoing invasive positive pressure ventilation.…”

“…In critically ill patients, the SVC variation is an effective indicator for evaluating the intravascular volume status and fluid responsiveness . Several studies indicated that the SVC diameter is easily measured with transesophageal echocardiography (TEE) during surgery . Our study aimed to estimate the effectiveness of the SVC diameter and variation in predicting fluid responsiveness in patients undergoing invasive positive pressure ventilation.…”