Accurate and prompt diagnoses are crucial to critically ill patients. Transthoracic echocardiography (TTE) has proved to be of great value in the critical care setting because of its portability, widespread availability, and instantaneous diagnostic capability. However, TTE is frequently unsatisfactory in the critical care setting due to the high percentage of technically inadequate studies in the critically ill patients, especially when the patient has chest wall interference or is mechanically ventilated. Transesophageal echocardiography (TEE), a new window to the heart, can overcome the constraints and provide more information about the cardiac abnormalities than TTE. Therefore, TEE is a useful adjuvant in the treatment of critically ill patients. However, only a few reports have described this important application of TEE in critically ill patients and to our knowledge, there have been no reports concerning the use of TEE in critically ill patients in the emergency department. In this study, we compared the usefulness of TTE and TEE in the treatment of critically ill patients in the ICU and in the emergency department in a 2-year period. canadian pharmacy mall
This study consisted of 80 critically ill patients in whom both TTE and TEE were attempted between July 1990 and June 1992. Of these, 48 patients were studied in the ICU, while the other 32 patients, directly referred from the emergency department, were studied in the Echocardiography Laboratory. There were 51 men and 29 women, ranging in age from 14 to 77 years, with a mean age of 53 years. At the time of TEE, 17 patients (21 percent) were intubated and mechanically ventilated. The TEE procedure was explained and informed consent was obtained in all cases.
Echocardiographic studies were performed with phase-arrayed ultrasound systems. (Toshiba SSH-65A, Toshiba SSH-270A, Toshiba Corp, Tokyo, Japan, and Aloka SSD-870, Aloka Co, Ltd, Tokyo, Japan). Monitor ECG with lead 2 was used during the echocardiographic studies. In each, TTE and TEE were performed using the same ultrasound systems. For the precordial studies, 2.5-MHz and 3.5-MHz transducers were used. For the transesophageal studies, a 3.75-MHz transesophageal phase-arrayed transducer was used with the single-plane ultrasound system (Toshiba SSH-65A) in the earlier 20 patients and a 5.0-MHz transesophageal probe was used with the biplane ultrasound systems (Toshiba SSH-270A and Aloka SSD-870) in the remaining patients. All the echocardiographic studies were performed within 4 h after the request. Transthoracic echocardiography was performed before TEE in all patients with the standard procedure described previously, including parasternal long-axis and short-axis views and apical four- and two-chamber views. In addition to the standard views, suprasternal and right parasternal views were also used in patients with suspected aortic dissection. Transesophageal echocardiography was usually performed with the patient in the left lateral decubitus position. In ventilated patients, the presence of a protected airway permitted examining the patient in the supine position. The patient fasted for at least 4 h before the transesophageal examination. Local anesthesia of the pharynx was achieved with 2 percent lidocaine (Xylocaine)
Data on the findings of TEE were compared with those of TTE by x2 analysis or Fishers exact test where appropriate. A p value <0.05 was considered as statistically significant, spray to suppress the gag reflex. The patients were given intramuscular meperidine (25 to 50 mg) to reduce anxiety and suffering. In ventilated patients, intravenous diazepam (2.5 to 5 mg) was added. The heart and aorta were studied in standard transesophageal projections as previously described. All echocardiograms were recorded on 1.875-cm videotape (U-matic Fuji KCA-60) or 1.25-cm videotape (Sony VIIS) and reviewed by two independent echocar-diographers. Any complications that occurred during the TEE studies were carefully recorded. The time required for transesophageal procedure was less than 15 min.