Utilization of Formal Echocardiography for Shock: The Emperor Has No Clothes

Abstract

PURPOSE: In the United States, standards for hemodynamic monitoring of patients with shock have changed. The once ubiquitous 'Swan' has lost favor thereby leaving only MAP, CVP, lactate and SvO2 measurements readily available. Various devices provide functional hemodynamic monitoring, although, their use remains sporadic secondary to mixed acceptance of the technology and expense. Intensivist-performed, goal-directed echocardiography can evaluate discrete elements of cardiac function, however, widespread use is limited by equipment and training requirements. Formal, cardiologist-read, transthoracic echocardiographs (TTEs) are ordered to evaluate cardiac function in patients with shock. We are investigating the prevalence of formal TTEs in patients with shock, the cost, and the reasons they are ordered. METHODS: 362 MICU/SICU patients, excluding CCU, met ICD-9 criteria for shock over the course of one year. We identified TTEs by code, itemized their cost, and the hospitalization costs. We interviewed housestaff to determine their reasons for ordering TTEs. We conducted a literature review to investigate if formal TTEs improve outcomes in patients with shock. RESULTS: 234 of 362 (65%) of patients with shock received a formal TTE. The total cost, excluding physician fees, was $73,578. With the addition of physician fees, TTEs cost an average of $750 per patient. Evaluation of ejection fraction, volume status, and wall-motion abnormalities were top reasons for ordering a TTE. No literature supported improvement in outcome related to TTE. CONCLUSIONS: Monitoring hemodynamic parameters in patients with shock is common and considered essential for the majority of those patients. TTEs are ordered to measure cardiac performance but are expensive and static. No literature supported that formal TTEs improve outcome in shock. Studies evaluating the utility and cost effectiveness of TTE are needed. CLINICAL IMPLICATIONS: Shock is expensive at the human, micro and macro economic levels. Choosing the best tests that affect outcomes will be of paramount importance for patient and economic health. The desired hemodynamic information might be obtained at lower cost and dynamically through functional hemodynamic monitoring. Formal evaluation of intensivist-performed echocardiography on outcomes should be evaluated.