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CRITICAL CARE AND TRAUMA

The Use of Transesophageal Echocardiography for Preload Assessment in Critically Ill Patients

Department of Anaesthesia, St. Michael’s Hospital, University of Toronto, Toronoto, Ontario, Canada

Address correspondence and reprint requests to Dr. Claude Tousignant, Department of Anaesthesia, St. Michael’s Hospital, 30 Bond St., Toronto, Ontario, Canada, M5B 1W8. Address e-mail to tousignantc{at}smh.toronto.on.ca

IV volume is often administered to patients in an intensive care unit (ICU) to improve cardiovascular function. We investigated the relationship between stroke volume (SV) and left ventricular (LV) size by using transesophageal echocardiography (TEE) in a population of 20 ICU patients and 21 postoperative cardiac surgical patients. We also examined whether LV end diastolic area (EDA), by TEE, could identify patients who increased SV by 20% or more (responders) after 500 mL of pentastarch administration. There was only a modest relationship (r = 0.60) between the EDA and the SV in all patients. No relationship could be found between the pulmonary capillary wedge pressure (PCWP) and the EDA in all patients. Both responder and nonresponder PCWP increased significantly after volume administration. Only responder EDA increased significantly after volume administration. Responders had significantly lower EDA (15.3 ± 5.4 cm²) and PCWP (12.2 ± 2.2 mm Hg) when compared with nonresponders (20.2 ± 4.8 cm²) and 15.9 ± 3.1 mm Hg, respectively). Few ICU patients and only those with a small EDA responded to volume administration. It was not possible to identify an overall optimal LV EDA below which most patients demonstrate volume-recruitable increases in SV.

Implications: In a ventilated intensive care unit and cardiac surgical population, transesophageal echocardiography and pulmonary artery catheter are sensitive in detecting changes in preload after volume administration. Few patients demonstrate volume-recruitable increases in stroke volume when compared to cardiac surgical patients. It is not possible to establish an overall end diastolic threshold below which a large proportion of ventilated patients respond to volume administration.

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