Abstract
BackgroundEchocardiography is increasingly performed among septic patients as a routine part of evaluation and management in the intensive care unit (ICU). The rate of unanticipated critical findings (e.g., severe left or right ventricular dysfunction or pericardial tamponade) on such echocardiograms is unknown. We evaluated a retrospective cohort of septic ICU patients in whom transthoracic echocardiography was performed as a routine part of sepsis management. In addition to identifying critical findings, we defined whether each critical finding was anticipated, and whether the clinical team responded to the critical finding. The primary outcome was rate of unanticipated critical findings, which we hypothesized would occur in fewer than 5% of patients. We also performed an exploratory analysis of the association between unanticipated critical finding and mortality, controlling for severity of illness.ResultsWe studied 393 patients. Unanticipated critical findings were identified in 5% (95% CI 3–7%) of patients (n = 20). Among the 20 patients with unanticipated critical findings, a response to the unanticipated critical finding was identified in 12 (60%) patients. An unanticipated critical finding was not significantly associated with 28-day mortality when controlling for admission APACHE II (p = 0.27).ConclusionsUnanticipated critical findings on echocardiograms in septic ICU patients are uncommon. The potential therapeutic relevance of echocardiography to sepsis is more likely related to hemodynamic management than to traditional cardiac diagnoses. Research studies that employ blinded echocardiograms in septic patients may anticipate unblinding for critical findings approximately 1 in every 20 echocardiograms.
Highlights
Echocardiography is increasingly performed among septic patients as a routine part of evaluation and management in the intensive care unit (ICU)
Of note, when a vegetation was identified on transthoracic echocardiogram (TTE), this was not considered an unanticipated critical finding if endocarditis was considered prior to obtaining the TTE; we considered positive blood cultures with a typical organism before the echocardiogram was ordered as suggesting that endocarditis was under diagnostic consideration
Unanticipated critical findings were identified in 5% of patients (n = 20)
Summary
Echocardiography is increasingly performed among septic patients as a routine part of evaluation and management in the intensive care unit (ICU). Appropriateness criteria suggest that transthoracic echocardiogram (TTE) is appropriate in the case of shock or situations where TTE is likely to change management, and a variety of studies suggest that TTE identifies findings that change management [12,13,14,15,16,17,18]. These studies have either been in populations with high likelihood of relevant findings (e.g., perioperative management of cardiac surgery patients) or have been analyzed under the assumption that echocardiography should direct management and reporting that echocardiography changes management [19]. The application of echocardiography in septic patients is often related to hemodynamic management, especially fluid administration [20,21,22]
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