title: The hemodynamically unstable patient in the intensive care unit: hemodynamic vs. transesophageal echocardiographic monitoring.
abstract: OBJECTIVE
  Transesophageal echocardiography is a diagnostic and monitoring modality. The objectives of our study were to compare the diagnoses obtained with continuous transesophageal echocardiography and hemodynamic monitoring in the intensive care unit, to determine interobserver variability of diagnosis obtained with both modalities, and to evaluate its impact.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Surgical intensive care unit.
  
  
  METHODS
  Consecutive hemodynamically unstable patients after cardiac surgery.
  
  
  METHODS
  At admission, unstable patients were monitored during 4 hrs with transesophageal echocardiography and standard hemodynamic monitoring. The critical care physician evaluated the patients based on all information except the transesophageal echocardiography at 0, 2, and 4 hrs and formulated a hypothesis on the most likely cause of hemodynamic instability. Transesophageal echocardiography information was provided after each evaluation. To evaluate interobserver variability, all the hemodynamic and echocardiographic information was gathered, randomized, and evaluated by five clinicians for the hemodynamic data and five echocardiographers for the transesophageal echocardiography data. The evaluators were blinded to all other information. Kappa statistics were used to evaluate agreement. Impact of transesophageal echocardiography was assessed retrospectively by using the Deutsch scale.
  
  
  RESULTS
  Twenty patients qualified for the study. The agreement between the hemodynamic and echocardiographic diagnosis showed a kappa at admission, 2 hrs, and 4 hrs of 0.33, 0.47, and 0.28. The interobserver agreement for the initial diagnosis (p =.014) and between all evaluators (p <.001) was significantly higher in the echocardiographic compared with the hemodynamic group. The transesophageal echocardiographic information was considered retrospectively to be essential in 34% and valuable in 34% of cases.
  
  
  CONCLUSIONS
  These observations support the belief that transesophageal echocardiographic monitoring in the intensive care unit is associated with higher interobserver agreement in diagnosing and excluding significant causes of hemodynamic instability for postoperative cardiac surgical patients.
authors.affiliation: Department of Anesthesiology, CHUM, Notre-Dame Hospital, Quebec, Canada.
authors.forename: Tudor
authors.initials: T
authors.lastname: Costachescu
authors.forename: André
authors.initials: A
authors.lastname: Denault
authors.forename: Jean-Gilles
authors.initials: JG
authors.lastname: Guimond
authors.forename: Pierre
authors.initials: P
authors.lastname: Couture
authors.forename: Stéphane
authors.initials: S
authors.lastname: Carignan
authors.forename: Peter
authors.initials: P
authors.lastname: Sheridan
authors.forename: Gisèle
authors.initials: G
authors.lastname: Hellou
authors.forename: Louis
authors.initials: L
authors.lastname: Blair
authors.forename: Louis
authors.initials: L
authors.lastname: Normandin
authors.forename: Denis
authors.initials: D
authors.lastname: Babin
authors.forename: Martin
authors.initials: M
authors.lastname: Allard
authors.forename: François
authors.initials: F
authors.lastname: Harel
authors.forename: Jean
authors.initials: J
authors.lastname: Buithieu
mesh_terms: D000328:Adult; D000368:Aged; D017548:Echocardiography, Transesophageal; D005260:Female; D006331:Heart Diseases / Q000601:surgery; D006439:Hemodynamics; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D015588:Observer Variation; D011182:Postoperative Care; D011446:Prospective Studies