الفهرس 
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Abstract
The study was conducted in an interdisciplinary care unit at Vivantes Auguste Viktoria Hospital, charité University, Berlin, Germany between January 2020 and April 2021, and included 175 patients (over 60 years of age), all consecutive enrolled patients were admitted to the ICU as emergent unplanned admissions. Written informed consent was obtained from each participant or his guardian prior to initiating the echocardiographic measurements. Patients were allocated into one group and recruited during their ICU admission. Patients were enrolled in the trial once the study investigators determined that the patient had met the inclusion and exclusion criteria. Before conducting the basic echocardiographic assessment of the patient, the senior ICU physician was asked to create a preliminary treatment strategy based on his recent data.
Components of the preliminary management plan included the patient’s breathing and ventilation plan, the strategy for monitoring the patient’s hemodynamics and circulatory status, the, other diagnostic tests, such as CT chest x-ray, and other laboratory tests, such as troponin, D-dimer, or blood cultures. The final part of the preliminary management strategy was the plan for treatment. As soon as the preliminary management plan was established, doctors who were participating in the study conducted the transthoracic echocardiography examination according to the study protocol.
The heart structure and function were assessed during the basic echocardiographic exam. This assessment was performed using various views of the heart.
Majority of patients had no pericardial effusion or pleural effusion. More than half patients had hypertrophied left ventricle. Regarding diastolic function of the left side of the heart, 74 patients had impaired diastolic function grade 1, 24 patients had impaired diastolic function grade 2, 6 patients had severely impaired diastolic function, while 37 patients can’t be detected because of atrial fibrillation. Regarding left atrium, more than half of the patients had normal size. Most patients had normal TAPSE. Aortic valve stenosis was detected in 8 patients, and aortic regurgitation in 27 patients. Tricuspid regurgitation was detected in 58.28% of patients and mitral regurgitation in 35.3% of patients. While 52 patients were hypovolemic, and 48 patients were hypervolemic.
Regarding noninvasive and high flow ventilation and O2 insufflation, no significant difference was discovered between patients’ planned and performed plans (Kappa > 0.60). Differences were found between planned and performed plans after echocardiographic findings regarding arterial access, pulse index contour continuous cardiac output (PICCO), as well as TEE (Kappa < 0.60, P ≥ 0.001). Meanwhile, a significant difference was found between plans regarding CVP (Kappa < 0.60, P ≤ 0.001).
Concerning investigations performed to the study patients, 64 cases reported differences in management plan (Kappa < 0.60, P < 0.001), while 111 cases had no differences in the plan (Kappa > 0.60, P < 0.001).
Unexpectedly, the use of pleural puncture, pericardial puncture, parenteral nutrition, antibiotics, and CPAP mode of MV did not alter significantly (Kappa > 0.60, P < 0.001) between the two treatment strategies.
Although there was a substantial difference in the use of coro-angiography, preload reduction, afterload reduction, right sided heart failure therapy, anticoagulation, cardioversion, and diuretics between the two strategies (Kappa < 0.60), the differences were significant (Kappa < 0.60, P < 0.001) regarding volume shift after the echocardiography.
In conclusion, echocardiography has spread into the world ICU over the last two decades. Medical intensivists with brief training in TTE have performed and correctly interpreted a focused TTE examination in critically ill patients using hand-held ultrasound units. It is a promising tool to help practitioners who care for the critically ill patients to understand the diagnoses and hemodynamics that affect the individual patient.
TTE provided new information and altered management in a significant number of patients.
We found significant differences between planned and performed procedures regarding respiratory support, circulatory monitoring, investigations, and therapy.
1. APACHE score is one of the most common scores used in intensive care units to assess disease severity according to current physiological measurements, age and previous health conditions and it wasn’t included our study design, therefore we recommend using it in future ICU studies to classify patients included.
2. The learning curve is steep for this technique, there is a variability in performance, and interpretation may be difficult in the presence of confounding factors i.e., spontaneously breathing versus MV patients, raised intra-abdominal pressure, obese patients, and patients with emphysematous chest as COPD patients.
3. Furthermore, examination using transesophageal echocardiography (TEE) was not included for this study because of COVID-19 pandemic at the time of the study and the possibility of infection spread. Although TEE has its own growing evidence base for its application in intensive care, the availability of hemodynamic information is clearly invaluable for informing clinical decisions.
4. The amount of fluid used, the type used, and the rate at which each fluid was given, affect the response test in these studies. Unfortunately, there is no agreed formulation for a standard fluid load although almost all studies use approximately the same formulation.
We detected the benefit of expanding the use of transthoracic echocardiography from a procedure performed only when considered useful, to a procedure performed routinely in the intensive care unit. So, we recommend routine TTE examination for all ICU patients regardless the cause of admission and all intensivists and anesthesiologists should be able to perform basic bedside transthoracic echocardiography examination using a hand-held unit in the ICU and recommend incorporating bedside goal- directed, limited TTE training course into intensivists’ training programs.