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)
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