8/13/2019 Hemodynamic Resuscitation in Sepsis Continuity is Key to Echocardiography in Hemodynamic Sepsis Managemen

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Issue 3 Thursday 21 March 2013 ISICEM News 1

Thursday 21 March 2013 Day 3The ofcial daily newsletter of the 33rd ISICEM

Anovel, and important, development in

echocardiography for the hemodynamic

management of sepsis will be explored on

Thursday morning, when a leading expert discusses

his experiences with the device.

As part of the Hemodynamic resuscitation

in sepsis session Jukka Takala (Bern University

Hospital, Switzerland) with set out his views

on the current situation in sepsis management,

before looking at continuous echocardiographyusing hTEE (ImaCor Inc, Garden City, NY, USA), an

approach that, he says, not only offers new dimen-

sions to patient assessment and management, but

is also easy to implement across a

department.

Speaking to ISICEM News

ahead of his presentation, Pro-

fessor Takala began by saying:

First of all, I think if we look at

the hemodynamic management

of sepsis in general, one has to

realize that the goals of hemody-

namic management in sepsis are

based almost entirely on expertopinions.

He continued: We dont have

any solid evidence concerning

what the goals actually should

be, and therefore the goals that are communicated

in various guidelines for example, the Surviving

Sepsis Campaign guidelines,1and so forth are

based on very weak evidence and mostly on expert

opinions, even though they are evidence-based.

Therefore, the hemodynamic management of

sepsis is clearly a very murky area in terms of having

actual, well-established evidence of what the goals

should be.

It is clear that the vast experience that we havein this field has certainly brought about a crafts-

manship in knowing roughly the areas where we

should be in primary resuscitation, but in terms of

having solid goals, it is clear there is very little solid

evidence for that.

Professor Takala stated: The next point I

would like to make is that, after the controver-

sies over classical hemodynamic monitoring, and

especially with the pulmonary artery catheter, new

technologies that have been introduced and new

approaches to goals for example, those based

on the Rivers trial [2] have been widely applied in

clinical practice without actually having any more

evidence than we ever had for any invasive or non-invasive monitoring device. So, even though there

are many new possibilities to assess the patient, we

are not better off in terms of how to manage these

patients.

He summarised: Thats really the background

as to why I think that new approaches are neces-

sary and why they are welcome: although at this

point, as I said, our

knowledge on how

to best utilise these

is fairly limited.Why does

Professor Takala

believe that there

is so little evidence

for these practices? Is it because it is hard to con-

duct studies in those patients? He replied: Well,

hemodynamics in the septic patient are complex,

and there is no way to simplify the approach. The

studies that have been done are usually based on

very simplistic goals and therefore having clear

answers in terms of how to approach individual

patients cannot really be answered by such trials.

Lets take, for example, if we have some trials

on different ways to manage blood pressureBloodpressure is influenced by so many factors that a

simplistic approach that doesnt take into account

the underlying pathophysiology cannot give you a

proper answer.

Looking specifically at continuously available

echo with hTEE, what are the principles and goals

of using this new method in hemodynamic man-

agement? The principles are just as in any type

of echocardiography, Professor Takala explained.

The novelty of this technology is that we have

a probe that can left in place for 72 hours and,

although the probe does not provide all the advan-

tages of, lets say, a modern echo device, it does

give the information needed to monitor the patientand evaluate the response to treatment.

He went on: Specifically, it is a thin, soft probe

which can be introduced like an orogastric tube

and left in place for 72 hours. Thats what the ap-

proval is for the maximum time of usage. Basically

I think that, most likely, such probes could be, in

the future, left in place for longer periods of time,

but this is how the approval is at the moment for

this device.

On the other hand, if you think about the

need for sophisticated monitoring of the circula-

tion, most likely we are talking patients about who

have an acute disorder that needs to be stabilised,

so that 72 hours is really, say, a fair timeframe for

achieving that.

What benefit does it have giving us that continu-

ous monitoring for that period of time?ProfessorTakala said: First of all, the benefits from echo-

cardiography in a traditional sense of diagnosing

disorders in patients is well-accepted, in that we can

get, essentially, information on cardiac function by

echocardiography that we cannot achieve by other

monitoring or diagnostic means.

The problem with classical echocardiography

is, first of all, the training of users is fairly intensive.

One needs to have a vast experience in echocardi-

ography before one can do a full echocardiographic

examination using the classical echo technology.

Thats point number one. Point number two is that

it gives you a cross section, whereas the problems

that we need to treat in these patients changedynamically over time, and repeating echocardi-

ography on a frequent basis in these patients is

impractical. And, of course, as I said, doing that 24

hours a day, seven days a week is often confronted

with logistic problems as well.

He added Now, this new technology offers the

possibility of getting the basic information with a

quite minimal amount of training, actually. When

we introduced the technology in our unit, most of

our staff had no training in esophageal echocar-

diography. We found out that, in fact, just with

short training of a few hours duration, you could

introduce the technology so that the investigations

by the staff with these devices could be performingvalidly.

We did a validation study such that we record-

ed the performance of the staff using a standard

approach for inserting the probe and to get the

information. This was then re-evaluated by a trained

cardiologist, an echo specialist, and we found an

excellent agreement between the information ob-

tained by the cardiologist versus our staff. So clearly

it can be introduced with a relatively minor or a

moderate effort, and also to users who have not

received a full training in echocardiography.

He concluded: In that sense it is, for me, a way

to enhance the acquisition of treatment-relevant

information from patients that we usually, untilnow, only had available from echocardiography

performed in a traditional manner.

References

1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Cam-paign: International Guidelines for Management of Severe Sepsisand Septic Shock: 2012. Crit Care Med 2013;41:580637.

2. Rivers E, Nguyen B, Haystad, S, et al. Early goal-directed therapyin the treatment of severe sepsis and septic shock. N Engl J Med2001;345:136877.

Continuity is key to echocardiographyin hemodynamic sepsis management

Jukka Takala

[hTEE] can be introduced

with a relatively minor or

a moderate effort, and

also to users who have not

received a full training in

echocardiography.

Jukka Takala (Bern University Hospital,

Switzerland)