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The association between Echocardiography use in the Intensive Care Unit and 28-day mortality among patients with septic shock: a systematic review
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The association between Echocardiography use in the Intensive Care Unit and 28-day mortality among patients with septic shock: a systematic review
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Content
The association between Echocardiography use in the Intensive
Care Unit and 28-day mortality among patients with septic shock:
a systematic review
By
Keith Killu MD
A Thesis Presented to the
FACULTY Of USC KECK SCHOOL OF PUBLIC HEALTH
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfilment of the
Requirements for the Degree
MASTER OF SCIENCE
(PUBLIC HEALTH)
December 2023
Copyright 2023 Keith Killu
ii
Table of contents:
List of tables……………………………………………………………………………...iii
List of figures……………………………………………………………………………..iv
Abstract...…………………………………..……………………………………………...v
Chapter One: Introduction………..……………………………………………………….1
Rational for conducting the study…………………………………………………2
Problem definition………………………………………………………………...2
Hypothesis statement……………………………………………………………...2
Type of exposures…………………………………………………………………2
Type of controls………………………………………..………………………….2
Objectives…………………………………………………………………………3
Chapter Two: Materials and methods….…………………………...……………………..4
Literature review…………………………………………………………………..4
Data sources……………………………………………………………………….4
Data search strategy………………………………….……………………………4
Inclusion and Exclusion criteria………………………..………………………....5
Data collection and processing……………………………………………………5
Chapter Three: Results…….………………………………………………………...........7
Search Results and Study selection……………………………………………….7
Study characterestics ……………………………………………………………..9
Analysis of outcomes ……………………………………………………………16
28 day mortality………………………………………………………….16
Fluid intake ……………………………………………………………...17
Lactate clearance ………………………………………………………..19
Inotropic support initiation ……………………………………………...19
Mechanical ventilation support ………...………………………………..20
Shock reversal time ……………………………………………………...21
Chapter Four:Discussion…………...…………………………….....................................23
Chapter Five: Conclusion……………………………......................................................27
Chapter Six: Bibliography ………………...…………………………………………….28
Chapter Seven: Appendix A………………………………………………………..……33
iii
List of Tables:
Table 1. Study and patients’ characteristics ……………………………………………………………………….10
Table 2. Study and patients’ results………………………………………………………………………………...11
iv
List of Figures:
Figure 1. PRISMA flow diagram……………………………………………………………………………8
Figure 2. Cochran collaboration tool for bias assessment………………………..…………………..9
Figure 3. Mortality rates…………………………………………………………………………………...17
Figure 4. Total fluid intake in a 24-hour period……………………………………...……………………..18
Figure 5. Rates of inotropic support initiation ……………….……………………………………………..20
Figure 6. Average mechanical ventilation free days……………………………………………..21
Figure 7. Average shock reversal time……………………………………………………………………….22
v
Abstract
The association between Echocardiography use in the Intensive Care Unit and 28-day
mortality among patients with septic shock: a systematic review.
Background: The development of septic shock in critically ill patients is a serious
condition that increases the probability of morbidity and mortality. Multiple modalities
are used to evaluate and manage hemodynamic derangements in septic shock patients and
most are invasive. Point of Care Ultrasound (POCUS) and Point of Care (POC)
echocardiography are non-invasive tools that are increasingly being used in the
assessment and management of adult patients with shock states. The goal of this
systematic review was to evaluate the association between performing POC
echocardiography on all-cause mortality among patients with septic shock in the
Intensive Care Unit (ICU) setting world-wide.
Methods: Study participants with septic shock were included in the systematic review.
Inclusion criteria were patients with septic shock, having a source or suspected source of
infection, hypotensive, receiving fluids and on vasopressor support. Septic shock patients
were treated in the ICU according to the Surviving Sepsis Campaign (SSC)1; 2; 3
guidelines for septic shock with or without the use of POC echocardiography guided
management. The data and literature search and extraction were conducted from 1990 to
May 2023. Five independent reviewers were included to review and eliminate any
potential biases in selection, performance, detection, attrition, and reporting of the data.
Bias was reported using the Cochran criteria for risk of bias assessment.
Results: A total of 1632 articles were identified in PubMed as potential studies to be
included from 1990 to May 2023. Of those, seven studies were included in the systematic
review with a total of 3812 patients included. Four studies were randomized controlled
trials (RCT), one was a retrospective case control study, and two were prospective cohort
studies. Following the SSC guidelines, POC echocardiography guided septic shock
management was compared to the standard of care which was SSC guidelines without the
use of POC echocardiography for managing patients with septic shock in the ICU.
POC echocardiography guided septic shock management was associated with a
statistically significant decrease in 28-day mortality in two studies, and non statistically
significant decrease in mortality in all other studies except one. There was a decrease in
the total amount of fluid received specifically in the first 24 hours of resuscitation in the
POC echocardiography group compared to the SSC group without echocardiography.
There was a significant association between initiation of inotropic support in the POC
echocardiography group compared to the SSC group in three of the studies with initiation
of inotropes in the other included studies. Mechanical ventilation free days was higher in
the POC echocardiography group compared to the control groups with no statistical
vi
significance. There were no significant differences in the shock time reversal across
studies.
Discussion: This systematic review evaluated the association between performing POC
echocardiography combined with the SSC guidelines in the evaluation and management
of septic shock patients and overall survival. The study strengths included reviewing
septic shock literature involving using echocardiography with the SSC guidelines and
comparing it to only SCC guidelines without echocardiography.
A limitation of our study was that some of the trials included were not RCTs.
Conclusion:
This systematic review shows that POC echocardiography guided management for
patients with septic shock decreases 28-day mortality and decreases the amount of fluid
received during resuscitation of septic shock and improve the use and initiation of
inotropic support when needed.
Chapter One: Introduction
Patients in septic shock with hemodynamic instability are usually admitted to the ICU for
frequent assessments, close monitoring, and management. Hemodynamic assessment and
treatment of patients with shock is usually challenging, with different etiologies and
variable assessment tools and management options. The scope of practice and the
complexity of care have evolved over the years, and mostthe management of septic
shock patients have evolved as well. Assessment of the hemodynamic and fluid status of
ICU patients might depend solely on clinical exams, and mostly on modalities developed
throughout the years5; 6. An example was in the early 70s, where the Pulmonary Artery
Catheter (PAC), also called the Swan Ganz catheter, named after H.J Swan and William
Ganz7 was introduced and widely used in the years to follow for assessment and
management of patients with shock states . This is considered an invasive tool employing
right heart catheterization into the pulmonary artery to better differentiate the types of
shock and monitor management progress. In the following two to three decades, other
less invasive modalities have been developed, and bedside ultrasound and
echocardiography guided management has become more commonly used in management
of shock.
POC echocardiography is a safe non-invasive modality for assessment and management
of patients with shock, with reproducible results. It is mostly used as part of an
assessment of the cardiac function as well as fluid status, and frequently in combination
with examining other organs by ultrasound8; 9; 10; 11
.
Septic shock remains a critical condition with a high 28-day mortality ranging between
34-50%12; 13; 14; 15; 16. Factors that can improve survival by improving hemodynamic
management of patients early in the event of septic shock should be considered3
. Many
critical care societies across the world have recognized the importance and the benefits of
using bedside Echocardiography by the critical care practitioner to assess and manage
patients with different types of shock16. Some recent trials have studied the use of
echocardiography in the assessment and management of septic shock patients showing
improved survival
17; 18; 19; 20; 21; 22; 23, with improved diagnostic accuracy17; 22; 24; 25
.
Systematic reviews and metanalysis examined the effect of using bedside ultrasound (not
specifically echocardiography) in the hemodynamic assessment of different types of
shock and found improvement in diagnostic accuracy26; 27
. A recent meta-analysis
examined the use of ultrasound in management of patients with septic shock, reviewing
studies by evaluating different protocols, including comparing effect of using point of
care ultrasound with lung exams, Inferior Vena Cava (IVC), passive leg raising, Central
Venous Pressures (CVP) on mortality rates but not specifically including
echocardiography28
.
2
Rational for conducting the study
Since the use of echocardiography in the diagnosis and management of septic shock has
shown some effects on survival and improving management, there is a need to conduct a
systematic review examining the effect of those studies using POC echocardiography in
managing septic shock patients and the effect on outcomes including the survival rates.
Problem definition
Hemodynamic assessment of the critically ill patients often requires invasive monitoring
for evaluation and management. Using noninvasive assessment as POC echocardiography
in septic shock is not as widely used and there is a lack of implementation in guidelines
of different critical care societies and organizations.
Hypothesis statement
Our hypothesis that patients with septic shock, when POC echocardiography is used to
assist in their hemodynamics evaluation and management, it will improve the 28-day
survival.
Sepsis and septic shock induced cardiomyopathy through left ventricular depression in
contractility has been studied and is a well-recognized entity29; 30; 31. Mortality of septic
shock is increased when associated with cardiomyopathy and left and right ventricular
dysfunction. Mortality will approach 50% in left ventricular systolic failure and 42% with
right ventricular failure32. Recognizing the associated cardiomyopathy during septic
shock and providing the needed inotropic support will help decrease overall mortality by
improving perfusion and can possibly lead to less fluids administered and less needed
vasopressor support.
Limiting the amount of fluid given for patients with septic shock can decrease tissue
edema which usually leads to organ dysfunction, as well as heart failure and renal failure
in patients with preexisting heart and kidney disease. Some studies and meta-analysis
have recommended limitation of the amount of fluid administered in septic shock
patients, although recent trial showing following the standard of 30 cc/kg as
recommended by the SSC guidelines have similar outcomes but not fluid overload33; 34; 35
.
Limiting the amount and duration of vasopressor support and decreasing the time for
shock reversal is of great importance since that can limit the complications associated
with vasopressors, including organ ischemia and tissue damage.
Types of exposures or intervention used:
Septic shock patients managed according to the SSC guidelines for septic shock plus
POC echocardiography to assist in management.
Types of control:
Septic shock patients managed according to the SSC guidelines for septic shock without
POC echocardiography.
3
Types of study designs used :
We included randomized controlled trials as well as retrospective and prospective cohort
studies.
Study populations:
Population included adult and pediatric patients with septic shock.
Objectives:
Our study aim is to conduct a systematic review evaluating studies that used POC
echocardiography combined with the SSC guidelines for septic shock management
compared to only SSC guidelines in evaluating and managing adult and pediatric
patient’s hemodynamics who are in septic shock and examine the impact of the POC
echocardiography exam on improving survival. Our systematic review includes studies
using POC echocardiography to evaluate septic shock and is not limited to a particular
protocol. 28-day mortality was reported.
4
Chapter Two: Materials and Methods
Literature Review
The reporting of the present review followed the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) statement36; 37
.
This systematic review identified and evaluated RCT as well as retrospective and
prospective cohort studies on patients with septic shock using POC echocardiography as
a modality for hemodynamic assessment, compared to no echocardiography use and
studying the survival outcomes.
Data sources
Studies were selected through the electronic PubMed database from January1990 till May
2023. Search of grey literature included keyword search, using commercially available,
search engines, including Google, Google scholar, and Bing. Search for the relevant
abstracts from national meetings, including the society of critical care, the society of
chest physicians, the American thoracic society, and from general meetings.
Data search strategy:
A comprehensive literature search was conducted in MEDLINE, EMBRACE, and web of
science. This was done by a librarian dedicated for this. All publications available
included in the search. The search strategy was created by reviewing Medical, Subject
Headings, and MESH terms, relevant to the area of interest. Combination of search terms
were constructed, and the search was conducted to ensure the inclusion of a small set of
known articles. Key reviews on the subject area were screened for additional relevant
references to supplement the final analysis. We included some studies from other metaanalysis of general ultrasound and septic shock that did not show on our literature search
and was in Chinese language where we used google translate for translation, verified by a
native Chinese speaking physician21
.
The data term used for search was as follows:
(Echocardiography[Mesh] OR echocardiograph* OR echocardiogram OR
((Hemodynamics[Mesh] OR Heart[Mesh] OR hemodynamic OR heart OR cardiac) AND
(Ultrasonography[Mesh:NoExp] OR ultrasonograph* OR ultrasonic OR ultrasound OR
echography OR echotomography))) AND ("Shock, Septic"[Mesh] OR
"Shock"[Mesh:NoExp] OR ((septic OR toxic OR endotoxic OR endotoxin OR
hypovolemic) AND (shock)) OR ((circulatory) AND (failure OR collapse))) AND
5
(Intensive Care Units[Mesh:NoExp] OR Burn Units[Mesh] OR Coronary Care
Units[Mesh] OR Recovery Room[Mesh] OR Respiratory Care Units[Mesh] OR
Postoperative Period[Mesh] OR Critical Care[Mesh:NoExp] OR Early Goal-Directed
Therapy[Mesh] OR Critical Care Nursing[Mesh] OR Critical Care Outcomes[Mesh] OR
Critical Illness[Mesh] OR "intensive care" OR ICU OR ICUs OR "burn unit" OR "burn
units" OR "burn center" OR "burn centers" OR ("coronary care" AND unit) OR
"recovery room" OR "recovery rooms" OR ("respiratory care" AND unit) OR "critical
care" OR "critical illness" OR "critically ill").
After the studies and data were extracted from Medline with the help of our librarian,
three authors independently reviewed all titles and abstracts for study selection. When
there was a dispute another two authors were involved in the discussion. Epidemiology
specialist reviewed all final studies selected with the main author and both selected the
final seven articles and removed the other articles that did not match the research
question. They reviewed the full text studies. All other authors were involved in the
search, reading final articles, and contributing to the manuscript.
Inclusion and Exclusion criteria:
The inclusion criteria were RCT as well as retrospective and prospective cohort studies of
adult and pediatric patients in septic shock who were treated following the SSC
guidelines for septic shock with Echocardiography for assessment and management and
this was compared to the standard in which only SCC guidelines were followed without
echocardiography in evaluating and managing patient’s hemodynamics with septic shock.
Studies included were published between 2014 and 2021. Six studies were in English and
one in Chinese languages.
The exclusion criteria were studies that did not specifically study septic shock patients,
studies that did not report on mortality. Studies that included sepsis patients instead of
only septic shock patients were not included, as well as studies investigating nonspecific
shock24; 27; 38. Studies that compared general ultrasonography as IVC or lung ultrasound
without echocardiography, were not included since other metanalysis have been done on
such studies39
.
This Systematic review was registered in Prospective Register of Systematic Reviews
(PROSPERO) (CRD42023429497)
Data Collection and Processing:
Individual data from each study were collected for patients who were managed using
echocardiography with the SSC guidelines for septic shock and were compared to data
from patients who were managed using the SSC guidelines for septic shock with no
echocardiography. The primary outcome studied was the 28-day survival.
6
Secondary outcomes studied included, the total amount of fluid received, the amount of
fluid received in the first 24 hours, the initiation and use of inotropic support, the lactate
clearance, and the mechanical ventilation free days and time to shock reversal.
We included studies with population including adult and pediatric patients evaluated and
treated for septic shock worldwide. The intervention involves using echocardiography in
combination with the standard SSC guidelines for evaluation and management of patients
with septic shock state. The standard of care and the control groups were managed using
the SSC guidelines without echocardiography in the evaluation and management of
patients with septic shock. Studies from 1990-2023 that met the criteria were included in
the search. Studies before 1990 were not included, since many advances in the use of
echocardiography happened since the early 1990’s.
For studies to be eligible, they had to include the primary outcome of 28-day mortality or
survival, and one or more of the secondary outcomes.
Five authors selected the articles and extracted the data. Each step in the selection was
done independently by each author. The authors were not blinded to the authorship, year
of publication or the journal.
Five authors assessed the quality of the selected studies for the presence of bias. Random
sequence generation collection examines whether there was a selection bias in patient
enrolment. Selection bias whether concealment of allocation was done. We examined if
there were incomplete data in outcomes reported and included in the bias assessment.
Explicit inclusion and exclusion criteria were reviewed in all studies and allocated a bias
assessment, as well as intention to treat analysis. Reporting on patient’s characteristics in
addition to similarity of care in both groups were considered as bias if not followed or
reported. Whether an outcome was described clearly was also important in description of
the study and biases to be reported. (Figure 2).
7
Chapter Three: Results
Search Results and Study selection:
1632 articles were identified as potential for review. 1631 were identified through
PubMed, and one article through Google search. The three Reviewers screened each
study title and abstract for eligibility based on inclusion criteria. The reviewers were not
blinded to the study journal, authors, or the year of publication. 1623 articles were found
to be irrelevant to our meta-analysis and were excluded. Nine studies were identified for
the full article review. Two further articles did not meet inclusion criteria after full article
review, and were excluded, one due to lack of intention to treat analysis after inclusion of
patients40 and the other did not differentiate outcomes between sepsis and septic shock
population studied41. The decision and reasons for inclusion or exclusion, is recorded on
the study screening form and PRISMA flow diagram. (Figure 1)
8
Figure 1: Preferred Reporting Items for Systematic Reviews and Meta analyses
(PRISMA) flow diagram.
To decrease the effect of bias, the Cochrane collaboration tool used to rate the quality of
a study’s evidence by examining the potential biases in selection, performance, detection,
attrition, and reporting. After the initial review by two reviewers, two additional
independent reviewers assessed the literature included for any bias. In cases of conflict an
additional reviewer reconciled any discrepancies. (Figure 2).
9
Figure 2: Cochran collaboration tool for bias assessment of the included studies
Study Characteristics and findings:
A total of seven studies were included for the final analysis which included 3885 patients
with septic shock. The study year, country, design, number of participants and the ICU
setting were reported. The echocardiography measurements and any other ultrasound
measures were documented for all studies. The average age of patients, their gender and
the cause of their septic shock and the results regarding the primary and secondary
outcomes were also reported17; 18; 19; 20; 21; 22; 23
. (Table 1 and 2).
10
Table 1. Study and patients’ characteristics.
11
12
Table 2: Study and patients’ results. IVC (Inferior Vena Cava, LV (Left Ventricle), SSC (Surviving Sepsis
Campaign), LV (Left Ventricle), MV (Mechanical Ventilation), RV (Right Ventricle), SOFA (Sequential Organ
Failure Assessment)
In a study by Kanji et al17, conducted in Canada, the group studied the effect of POC
echocardiography–guided therapy in subacute shock and its association with change in
management and outcomes. The study examined a retrospective cohort using the standard
of care, and a prospective cohort study using POC echocardiography. Each cohort
included 110 patients. It was conducted in a single center, involved 220 adult ICU
patients with most patients over 86% were being treated with septic shock although all
were considered in a septic shock and treated accordingly. The intervention was using
POC echocardiography in management of patients with septic shock in addition to the
SCC guidelines for septic shock versus only the SCC guidelines for septic shock.
Baseline echocardiography was done within 24 hours from the admission to the ICU
followed by another echocardiography exam at 36 hours. Left ventricle (LV) eyeball
qualitative function assessment was used to determine the left heart function. IVC
diameter and respiratory variation for fluid status was also done to aid in management.
The 28-day survival analysis favored patients receiving POC echocardiography group,
with a 28-day mortality rate of 36 patients (33.6%) vs 47 patients (43.6%) (P=.04) in the
standard management group. The POC echocardiography group cohort had a
nonsignificant trend towards more days alive and free of mechanical ventilation (20 days
vs 18 days, P = 0.565). The amount of intravenous fluid received during the first 24 hours
were 49 (mL/kg) in the POC echocardiography group vs 66 (mL/kg) in the nonechocardiography group, P=0.04. Inotropic support in the form of Dobutamine was
initiated in 22 patients (24%) in the POC echocardiography group vs 12 patients (14%) in
the non-echocardiography group P=0 .01. Acute kidney injury was also reported to
develop in 19 (20%) patients in the POC echocardiography group, versus 19 (20%)
patients in the non POC echocardiography group, P=0.013.
Assessment of bias for this study, there was no random sequence generation, since it was
not RCT, and there was no allocation concealment in this study, because it is almost
impossible to conceal. There were no explicit inclusion and exclusion criteria reported in
this study.
El-Nawawy et al18 studied the role of echocardiography in reducing shock reversal time
in pediatric septic shock. This was a RCT of a single tertiary care center in a Pediatric
ICU. They recruited 90 pediatric patients from 1 month to 11 years old. Most common
source of septic shock was the blood stream infection. Patients were randomized into a
control group that had their management following the SCC septic shock guidelines, and
a group following the SCC septic shock guidelines in addition to using POC
echocardiography to assist in management. Serial echocardiography guided therapy to
assess myocardial function and volume status. Baseline echocardiography within 24
13
hours from admission to the ICU was done. LV eyeball qualitative function assessment
was done as well as LV M Mode quantitative function assessment to evaluate the left
heart. Diastolic function assessment was done by E/A ratio. IVC diameter and
respiratory variation for fluid status were also recorded for each patient. Repeated
echocardiography exams were done when there was a change in management. There
were no significant differences in the initial physiological variables, except for initial
heart rate, which was higher in the study group. There was a significant improvement in
all measured variables at the three-timepoints (1, 6, and 24 hours) when compared with
the initial values in both groups.
Mean arterial pressure (MAP) was significantly higher in the study group at 1 hour and
24 hours. Shock reversal time (improvement in MAP) was 78 hours in the POC
echocardiography group and 108 hours in the control group respectively, P= 0.01.
Resuscitation time was 6 hours in the POC echocardiography group and 24 hours in the
control group, respectively, P<0.001. There was no significant difference in survival
among the POC echocardiography group 32 patients (71.1%) and 28 patients (62.2%) in
the control group respectively, P=0.371, although the mortality for deceased patients with
unresolved shock state was 5 (38.5%) in the POC echocardiography group and 15
(88.2%) in the control group respectively, P=0.006. The initiation of inotropic support
was 40 patients (88.9%) in the POC echocardiography group and 30 patients (66.7%) in
the control group respectively, P= 0.011. The total amount of fluids received in the first
24 hours was 86 ± 24.5m(mL/kg) in the POC echocardiography group, and 98.2 ± 26.2
(mL/kg) in the control group, (a reduction of about 13%), P=0.027. The lactate levels at
24 hours were lower in the POC echocardiography group at 2.46 ± 1.87, and 1.72 ± 0.8 in
the control group, P=0.001.
Assessment of bias for this study, there was no allocation concealment or blinding in this
study. The period of the mortality rate was not specifically identified.
Lanspa et al19 conducted a single center study in the United States, which was a
feasibility RCT of POC echocardiogram-guided resuscitation versus early goal-directed
therapy using the SSC guidelines in the treatment of septic shock. The study included 30
adult patients with septic shock randomized into two groups, the control group were
patients with septic shock being managed following the SCC guidelines for septic shock,
and the intervention group was managed using the SCC guidelines for septic shock in
addition to POC echocardiography.
In the POC echocardiography arm, assessment of the LV, Right Ventricle (RV) function
was determined in a qualitative manner by eyeballing method. Fluid status assessed,
where examination of the IVC diameter and collapsibility measurement were done. The
median change in Sequential Organ Failure Assessment (SOFA) score (a lower value is
more favorable) was − 4 in the POC echocardiography arm compared to − 6 in the
control arm (p = 0.10). There was no significant difference between the POC
echocardiography and control arms in the amount of fluid received due to the study
protocol, median 0 L and 1 L respectively, p = 0.61. Three subjects (20%) in the POC
echocardiography arm received inotropic support in the form of dobutamine compared to
14
two subjects (13%) in the control arm (p > 0.99). The inpatient mortality was reported
as 3 (20%) in the POC echocardiography group versus 5 (33%) in the control group, p =
0.68. ICU-free days were median 24.2 in the POC echocardiography and 24.5 days in the
control group, p = 0.97. Fluid administration in the first 24 hours was 6 Liters in the
POC echocardiography group and 6.4 liters in the control group, p= 0.63. Finally, the
ventilator-free days also appeared similar across groups, and they were 28 days in the
POC echocardiography group and 25 days in the control group, p = 0.51.
Assessment of bias for this study, there was no allocation concealment or blinding in this
study.
The study by Lan et al20, is the largest conducted so far and included 3291 adult patients
with septic shock in a retrospective analysis of the Medical Information Mart for
Intensive Care III (MIMIC-III) database. Septic shock patients were treated according to
the standard of care and the SSC septic shock guidelines with POC echocardiography
was used to aid in the management of 1289 patients and compared to the management of
1289 patients with septic shock using SSC septic shock guidelines without
echocardiography. The POC echocardiograms were done within 24 hours of the diagnosis
of septic shock. The details on the echocardiography assessment were not reported for the
study. After using the propensity-score matching (1:1 matching ratio), the POC
echocardiography group had a significantly lower 28-day mortality 486 (33.2%)
compared to 428 (37.7%) in the control group, P=0.019. More patients in the POC
echocardiography group received inotropes, 229 patients (17.8%), compared to 92
patients (7.1%) in the control group. The POC echocardiography group had marginally
longer norepinephrine durations while no difference was observed with mechanical
ventilation free days, 20.8 days in the POC echocardiography group and 20 days in the
control group, p=0.446. There was a trend showing patients in the POC echocardiography
group receiving more fluid during resuscitation, although it was not statistically
significant compared to the control group, group 5010 ml, and 4674 ml respectively,
p=0.42. The shock reversal time was almost equal in both groups, the POC
echocardiography group 1.3 days and 1.1 days in the control group, p=0.007.
Assessment of bias for this study, there was no allocation concealment or blinding in this
study. Adequate patient descriptions were not clear, and the inclusion and exclusion
criteria were not as clear.
In a study by Li, G et al21, conducted in a single center and evaluating the clinical value
of early liquid resuscitation guided by passive leg-raising test combined with
transthoracic POC echocardiography in patients with septic shock, the authors studied 74
adult patients with septic shock comparing the standard of care using the SSC guidelines
in management of septic shock to an investigative arm adding leg raising to assess fluid
responsiveness detected by POC echocardiography. Mean Arterial Pressure (MAP),
Central Venous Pressure (CVP), Saturation Central Venous Oxygen (SCVO2) were
measured for all patients. The goal of the study was to achieve map >65, CVP 8-12, and
15
SCVO2 > 70, with fluids followed by vasopressors if not successful. The POC
echocardiography group measured the Stroke Volume (SV), with Stroke Volume
Variation (SVV) and its variation from before and after leg raising. Results showed
significant difference in the SCVO2 in 6 hours, 0.70±0.04 in the POC echocardiography
group compared to 0.63±0.05 in the control group, P<0.01. The lactate clearance within 6
hours was significantly better in the POC echocardiography group at 2.52±1.15 compared
to 3.89±1.42 in the control group. The Partial Pressure of Oxygen: Fraction of Inspired
Oxygen (P:F) ratio was also better in the POC echocardiography group at 338.14±27.47
compared to 303.35±22.52 in the control group, P<0.01. Hospital stay was significantly
lower in the POC echocardiography at 21.47±5.58 and 28.33±4.93 days in the control
group, P<0.001. There was no difference noted for in-hospital mortality, 7 (18.9%) in the
POC echocardiography group versus, 7 (18.9%) in the control group.
Assessment of bias for this study, there was no allocation concealment or blinding in this
study. Adequate patient descriptions were not clear, and some incomplete outcome data.
The study by Li, Li et al22
, was a RCT conducted on 94 patients with septic shock
between 2014 and 2016 in a single center. After randomization the control group was
treated according to SSC guidelines for septic shock and compared to the intervention
where the patients were treated according to SSC guidelines for septic shock plus POC
echocardiography. The echocardiography exam included LV Ejection Fraction (EF)
estimation by eyeballing. Lung ultrasound to evaluate for pulmonary edema was also
conducted as well as IVC measurement. Repeated POC echocardiography exams were
done as seen necessary by the treating physician. The primary outcome was the effect of
cardiopulmonary POC echocardiography on 28-day mortality, which was not
significantly different between the two groups 50.6% in the POC echocardiography group
and 60.0% in the control group, p= 0.58. Fluid balance volume within the initial 6 hours
in the POC echocardiography group was almost 600 mL more than that in the control
group 2092.0 ± 1452.9 and 1508.9 ± 1211.8 mL, respectively, P=0.04. The POC
echocardiography group tended to have a shorter duration of vasopressors support
compared to the control group, 48 hours (interquartile range, 24.0– 83.5 hours) and 69
hours (interquartile range, 34.0–97.9 hours) respectively, P=0.48.
Time to lactate normalization was shorter in the POC echocardiography group at 18.5
hours (7.3–69.0) compared to 19.0 hours (11.5–213.0) in the control group. P= 0.61. The
shock reversal time was shorter in the POC echocardiography group compared to the
control group although was not statistically significant, 48 hours and 69 hours
respectively, P=0.08. The 28-day mortality rate was not significantly different between
the two groups 50.6% in the POC echocardiography group compared to 60.0% in the
control group, p= 0.58.
Assessment of bias for this study, there was no allocation concealment or blinding in this
study. The inclusion and exclusion criteria were not clearly stated. A
16
Yu et al23 conducted a RCT on septic shock patients evaluating the effect of critical care
ultrasonography including POC echocardiography on clinical parameters including
lactate clearance, fluid administration and the 28-day survival. This was a single center
study in a general ICU, included 86 patients who were randomized using block
randomization. The control group was treated according to SSC guidelines for septic
shock, while the intervention was using the SSC guidelines in addition to POC
echocardiography for the management of the septic shock. The IVC and lung ultrasound
were used to help in the assessment. POC echocardiography guided therapy was with LV
study with EF estimation by eyeballing, RV assessment with Tricuspid Annular Plane
Systolic Excursion (TAPSE), SV, E/A ratio, Superior Vena Cava (SVC), IVC evaluation,
and lung ultrasound with B Lines assessments.
There were no significant differences in baseline characteristics between the two groups
The 6-hour lactate clearance was significantly better in the POC echocardiography group
than control group 23.8% and 9.7%, respectively; P = 0.010. The cumulative fluid
infusion volume and fluid balance at 12 and 24 h were significantly lower in the POC
echocardiography than the control group, with the 25th and 75th percentile, -270, 2304 ml
in the POC echocardiography group and 780.8, 3583.3 in the control group, P =0.031.
The 28-day mortality was non significantly lower in the POC echocardiography 38.1%
compared to 38.6% in the control group, P =0.95.
Assessment of bias for this study, there was no allocation concealment or blinding in this
study.
Analysis of outcomes:
The primary outcome for this review is to improve 28-day mortality in septic shock
patients by using Echocardiography to assist in management.
All seven studies included data on 28-day mortality in the experimental
echocardiography group and compared it to the control group with no echocardiography.
An overview of the 28-day mortality is presented in (Figure 3).
A summary of the variables and outcomes measured, were the following:
a) 28-day mortality, (Figure 3): Among all the 7 studies reporting on the 28-day
mortality, three studies reported this as a primary outcome, Kanji et al17, Lan et
al20 and Li, Li et al21. The other four studies reported this as a secondary
outcome. In Kanji et al, the 28-day mortality rate was 33.6% vs 43.6% (P=.04).
EL Nawawy reported no significant difference in mortality among the Echo
group 28.9% in the echocardiography group vs 37.8% in the control group P
=0.371. There was no significant difference in the mortality reported by the
Lanspa study, where they reported an inpatient mortality of 20% in the
echocardiography group versus 33% in the control group, p = 0.68. Lan et al
17
reported a 28-day mortality of 33.2% in the echocardiography group vs. 37.7%
in the control group, P=0.019. The 28-day mortality in Li, Li et al study was not
significantly different between the two groups 50.6% in the echocardiography
group vs. 60.0% in the control group, p= 0.58. They reported though a
significant mortality rate for deceased patients with unresolved shock state
which was 38.5% in the Echocardiography group vs 88.2% in the control group
P=0.006. The mortality was the same at 18.9% for both groups in the Li, G
study with P>0.05. Yu et al reported a 28-day mortality with no significant
difference in the echocardiography group at 38.1% and the control group 38.6%,
P =0.95.
Figure 3: Mortality rates as reported by study among the echocardiography
groups compared to the control groups.
b) 24 Hour/and total fluid intake (Figure 4): All studies included the 24-hour fluid
received, except Li, G et al21 which described the fluid outcome as development
of pulmonary edema as a percentage of the cohort. Some studies reported the
intake as a total and others as a milliliter per Kg. Kanji et al reported the 24-hour
fluid average received of 49 ml/kg (total 3430 ml) in the echocardiography
group less than the 66 ml/kg (total 4620) in the control group, P =0.04. El
Nawawy study reported less fluid received in the first 24 hours in the
echocardiography group, average of 86 ml/kg (total 481 ml) versus 98 ml/kg
18
(total 735 ml) in the control group, P =0.027. For both the Kanji and El Nawawy
trial we calculated the total amount of fluid by multiplying the reported ml/kg by
the actual average weight reported by El Nawawy study and by an average
weight of adult 70 kg for the Kanji study, since only BMI was reported. The El
Nawawy fluid was less than all other studies since this was done in pediatric
population. The fluid received in the echocardiography group in the Lanspa
study was less than the control group but not statistically significant, 6 L in 24
hours versus 6.4 L respectively, P = 0.63. The one study that showed the
echocardiography group receiving more fluid than the control group was the Lan
et al study, although this did not reach statistical significance, where the 24 hours
fluids received in the echocardiography group was 5.01 L versus 4.67 L, P
=0.42. In Li, Li study the reported 24-hour fluid was less in the
echocardiography group versus the control group with no significance, 5.8 L
versus 5.9 L, P = 0.69. In Yu et al, they reported the 24-hour fluid balance as the
25th and 75th percentile, at the echocardiography group and the control group, -
27.0, 2304.0 ml (median 1138.5 ml), and 780.8, 3583.3 ml (median 2182.05 ml)
respectively, P 0.031.
Figure 4: Total fluid intake in a 24-hour period in the echocardiography groups
compared to the control groups.
19
c) Lactate clearance: The reporting on the lactate clearance was variable among
studies. Five studies reported on lactate clearance, El Nawawy et al18, Lanspa et
al19, Li, G et al21, Li, Li et al22 and Yu et al23. The reporting varied in reporting
the initial levels followed by 6 hour or 24 hours levels. Lanspa et al reported on
the initial levels only since 70% of their participants have cleared their lactate
before measurement due to emergency department resuscitation prior to
enrollment. El Nawawy reported lactate level at 24 hours to be lower in the
echocardiography group versus the control group, 1.72 and 2.46 respectively, P
=0.001. In the study by Li, G the lactate clearance was reported to be better in
the echocardiography group compared to the control group at 6 hours, 2.52
versus 3.89 respectively, P <0.01. In the study by Li, Li, they reported on the
duration it took for the lactate to clear, and there was no significant difference
between the two groups, 18.5 hours in the echocardiography group versus 19
hours in the control group, P 0.61. The lactate clearance in the Yu trial was
reported as a percentage of clearance in the first 24 hours, where the lactate in
the echocardiography group cleared at 34. 2%, and in the control group cleared
at 19.8% in 24 hours, P =0.11.
d) Inotropic support initiation (Figure 5): Initiation of inotropic support was
reported in five studies, Kanji et al17, El Nawawy et al18, Lanspa et al19, Lan et
al20, and Li, Li et al22. The percentage of patients started on inotropy was
reported in those studies. The two studies of Li, G et al21 and Yu et al23 did not
report on initiation of inotropic support. Kanji et al reported initiation of
inotropic support in the echocardiography group at 22% versus 12% only in the
control group, P =0.04. In the El Nawawy study they also observed a higher
percentage of patients where inotropic support was initiated in the
echocardiography group, 88.9% versus 66.7% in the control group, P =0.006.
A trend towards initiation of inotropic support was higher in the echocardiography
group versus control group in Lanspa study at, 20% and 13% respectively, P>0.99. In
the largest cohort of Lan et al, the initiation of inotropic support was significantly
higher in the echocardiography group than in the control group, 17.8% and 7.1%
respectively, P =0.001. Li, Li et al reported a non-significant difference in inotropic
support initiation in the echocardiography group and the control group, 8.2% and
4.4% respectively, P =0.68.
20
Figure 5: Rates of inotropic support initiation in the echocardiography groups compared
to the control groups.
e) Mechanical ventilation duration (Figure 6): The mechanical ventilation duration
or free days off mechanical ventilation were reported by all except El-Nawawy
et al18 and Li, G et al21. In the study by Yu et al23, they reported also the 25th and
the 27th percentiles for both echocardiography group and control groups. Kanji et
al reported on mechanical ventilation free days to be more in the
echocardiography group than the control group with no significant values, 20
versus 17 respectively, P 0.57. Lanspa et al also found that mechanical
ventilation free days to be more in the echocardiography group than the control
group with no significant values, 28 days versus 25 days, P =0.51. In Lan et al
study, where mechanical ventilation free days were noted to be about the same in
both groups, in the echocardiography group and the control group with no
significant values, 20.8 versus 21 days respectively, P =0.446. A total duration
of mechanical ventilation was reported by Li, Li study, where the
echocardiography group had an average of 60 hours versus 62 hours in the
control group, (25.5 days and 25.42 days), P =0.72. In Yu et al, the median free
21
days for mechanical ventilation were 13 for the echocardiography group and 9
for the control group, P =0.29.
Figure 6: Average mechanical ventilation free days in the echocardiography groups
compared to the control groups.
f) Shock reversal time (Figure 7): This was reported by three studies, El Nawawy
et al18, Lan et al20
, and Li, Li et al22
. The other three studies did not report on
shock reversal time or the vasopressor time administered where extraction of
times would be possible. El Nawawy reported a significant difference in the
shock reversal time comparing the echocardiography group at 78 hours to
reverse shock versus 108 hours in the control group, P =0.01. Lan et al, the
shock reversal time was slightly longer in the echocardiography group, 1.3 days
than the control group 1.1 days, P =0.007. Li, Li et al showed the shock reversal
time to be non-significantly shorter in the echocardiography group compared to
the control group, 48 hours, and 69 hours respectively, P =0.08. Yu et al23
reported on the vasopressor free days to be more in the echocardiography group
compared to the control group, 20 days and 13 days respectively, P =0.29.
22
Figure 7: Average shock reversal time in hours in the echocardiography groups
compared to the control groups.
23
Chapter Four: Discussion
In our review we included studies that investigated the use of POC echocardiography
with the SSC guidelines to manage septic shock patients in the ICU and compared to SSC
guidelines without the POC echocardiography, to find the effect on mortality and other
secondary outcomes.
Evidence from the seven studies included in this review show the value in using POC
echocardiography when assessing and managing patients in septic shock. We found
evidence that it can improve survival, affect the choice of initiating inotropic support
which can be vital when there is myocardial dysfunction due to septic shock. Limiting the
amount of fluid and improving perfusion with shorter period to clear lactate is significant
in this population.
In a recent meta-analysis, Lin et al42
, studied the association of sepsis induced
cardiomyopathy and mortality, and described the increased 28-day mortality in patient
with sepsis induced cardiomyopathy compared to those without the cardiomyopathy.
Even higher rates were noted in patients who developed RV failure with RR 1.72, p
<0.01, and those were identified by using the POC echocardiography.
A study of septic shock patients as well as sepsis patients was conducted by Sekiguchi et
al 24
, where they examined this population and studied the effect of cardiac ultrasound on
the evaluation of hemodynamics parameters. Without echocardiography the treating
provider was not able to identify an LV dysfunction in about 40% of cases and an RV
dysfunction in 50% of cases. When POC echocardiography was implemented, those
providers changed their management in 27% (95% CI 14–44%) of cases. These changes
indicate that those providers were treating their patients with less knowledge about the
cardiac status of these patients and adding the POC echocardiography provided them with
further knowledge to better understand the physiological changes happening, to make the
necessary changes.
A recent systematic review by Berg et al27, examining the diagnostic accuracy of POCUS
in patients with undifferentiated shock, not specifically septic shock in the emergency
department. They all included POCU echocardiography in their assessments, and they
found an improved diagnostic accuracy, from 45-60% to 80-89% when combined with
clinical information and they also reported on changes in fluid administered and
vasopressor requirements although no statistical differences noted.
Using POC echocardiography has shown in all the studies included in this review to
decrease mortality with two of the studies, including the largest two cohorts with
significant results Kanji et al17 and Lan et al20
. The mortality in El Nawawy et al18 among
the deceased patients from septic shock also showed a significant decrease in patients
with POC echocardiography compared to the control group, 38.5% in the POC
echocardiography group and 88.2% in the control group respectively, P=0.006. The other
four studies all showed a non-significant decrease in 28-day mortality, with the exception
of Li, G et al21 which showed equal mortality rates and was one of the smaller trials. Lack
24
in significant values in the four studies can be explained by the smaller sample size of
enrolled patients affecting the overall significance of results.
Our review also showed the effect of using POC echocardiography on the amount of fluid
given to patients with septic shock, especially during the first 24 hours. Three studies,
Kanji et al 17, El Nawawy et al18 and Yu et al23 all showed significantly less fluids
administered in the investigation arm compared to the control group. El Nawawy showed
smaller amounts since theirs was a pediatric population. Only Lanspa et al19 showed more
fluid in the control group but, that was not significant, since there was fluid administered
to their patients in the emergency department prior to arriving to the ICU, which might
have affected the results and significance. Another way for reporting the fluid
administered was used by Li, G et al21, where they reported a significant difference in
developing pulmonary edema due to fluid overload in the control group (37.8%)
compared to the POC echocardiography group (13.5%), P <0.001. This was not included
in Figure 4, since we did not have the number of fluids liters in each group.
Lactate clearance was also reported in five studies, El Nawawy et al18, Lanspa et al19, Li,
G et al21, Li, Li et al22 and Yu et al23. The reporting on lactate was different with
different institutions. Some reported as clearance in 6 hours or 24 hours, others gave
absolute values at 6 hours, and others gave the percentage of decrease of lactate with
time. El Nawawy et al18 reported a significant decrease within the first 24 hours while Li,
G et al21 showed significant decrease in the first 6 hours. The protocols that institutions
follow, as well as their reporting, and since some were retrospective cohorts, may have
affected the reporting and following their institution protocols.
The initiation of inotropic support is of great importance if there is cardiac dysfunction or
cardiomyopathy associated with septic shock. We found that five studies have reported
on the initiation of inotropic support during the management of septic shock patients in
the POC echocardiography arm. Three trials including Kanji et al17, El Nawawy et al18
and Lan et al20 which were the largest cohorts all showing a significant increase in
inotropic support during the management of patients with septic shock.
We did not find a significant difference in the mechanical ventilation free days in both
groups, although there were more non-significant mechanical ventilation free days in the
POC echocardiography group. The source for the septic shock was reported between
about 20%-85% to be secondary to pulmonary cause. The need for mechanical
ventilation could be secondary to the shock state itself or an underlying pulmonary cause.
No reporting on the mechanical ventilation modalities used in different studies, nor there
were reports about the protocols used to manage those patients with respiratory failure
requiring mechanical ventilation. POC echocardiography could help in assessment of
pulmonary edema which may contribute to the status of the respiratory failure and the
need for mechanical ventilation, and since this was not the reason for doing the POC
echocardiography in those selected studies, this variable may have not been designed to
be studied and evaluated by the investigators.
The shock reversal time was reported by three studies. El Nawawy et al18 and Li, Li et
al22 with shorter shock reversal times, although only El Nawawy showed a significant
25
difference. Li, Li et al also reported on the vasopressor support duration in the POC
echocardiography group compared to the control group, with no significant values, at 48
hours and 69 hours respectively, P =0.48. The third study to report on the shock reversal
time, was the Lan et al20, with a non-significant result favoring the control group as well
as reporting on the duration of vasopressor requirements which was significantly higher
in the POC echocardiography group compared to the control group, 1.15 days, and 0.99
days respectively, P =0.032. In the study by Yu et al23, they also reported that the need
for vasopressor support was less in the POC echocardiography group compared to the
control group, 20 free days and 13 free days of vasopressors respectively, P =0.291.
Clinical implications and future perspectives:
This review identifies the substantial value of using the POC echocardiography in the
evaluation and management of septic shock patients. This technology assist in identifying
patients who have developed cardiomyopathy related to septic shock or already have an
existing underlying cardiac disease where POC echocardiography will help guide the
management accordingly. Patients with compromised cardiac function will need further
evaluations for the need of inotropic support, as well as using the vasopressors to
augment the blood pressure and maybe using less fluids for resuscitation to achieve that.
Improving the cardiac output, will lead to improving the perfusion of all organs, leading
to less organ damage and need for further assistant devices like renal replacement
therapy. Identifying the fluid status of a patient using the ultrasound and POC
echocardiography can also assist in administering less total fluid for resuscitation which
may save organ congestion and failure.
Integrating the POC echocardiography in the assessment and management of septic shock
in the future, as well as its application for all types of shock assessment can add value and
standardize care throughout different practice settings. We hope this can be included and
integrated in the upcoming guidelines for managing septic shock patients through
different societies, like the SSC guidelines3
.
Limitations:
Along with the multiple strengths of this review and the promising value, the review had
multiple limitations. The studies included were not all RCT, which can lead to some bias
and suboptimal selection and randomization, leading to different effects. Blinding in such
trials where POC echocardiography is used is not achievable, and this could have affected
the results through a selection and possible reporting biases. Some trials did not include
an intention to treat analysis, or clear distinction between sepsis and septic shock, those
were eliminated, and could have affected outcome. Our efforts in contacting multiple
authors for clarifications on multiple occasions were not successful.
26
Comparing different outcomes where it was not reported by all studies can lead to
selection bias, although we tried to report on all that was relevant to our review regardless
of results. The trials conducted were done in different fashions and used different POC
echocardiography protocols or part of a protocol to implement in those septic shock
patients, which make it difficult to compare. The control arm was the same for all
following the SSC guidelines.
27
Chapter Five: Conclusion
This systematic review demonstrates that implementing POC echocardiography to assess
and manage patients with septic shock in the ICU, along with the SSC guidelines, can
help improve the 28-day mortality, improve the choice to initiate inotropic support when
needed, and also may lead to a shorter shock reversal time and less amount of fluids
needed to resolve the shock state.
28
Chapter Six:Bibliography
1 DELLINGER, R. P. et al. Surviving sepsis campaign: international guidelines for
management of severe sepsis and septic shock: 2012. Crit Care Med, v. 41, n. 2, p. 580-
637, Feb 2013. ISSN 1530-0293. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/23353941 >.
2 RHODES, A. et al. Surviving Sepsis Campaign: International Guidelines for
Management of Sepsis and Septic Shock: 2016. Intensive Care Med, v. 43, n. 3, p. 304-
377, Mar 2017. ISSN 1432-1238. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/28101605 >.
3 EVANS, L. et al. Surviving sepsis campaign: international guidelines for management of
sepsis and septic shock 2021. Intensive Care Med, v. 47, n. 11, p. 1181-1247, Nov 2021.
ISSN 1432-1238. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/34599691 >.
4 BERTHELSEN, P. G.; CRONQVIST, M. The first intensive care unit in the world:
Copenhagen 1953. Acta Anaesthesiol Scand, v. 47, n. 10, p. 1190-5, Nov 2003. ISSN
0001-5172. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/14616314 >.
5 MCGEE, S.; ABERNETHY, W. B.; SIMEL, D. L. The rational clinical examination. Is
this patient hypovolemic? JAMA, v. 281, n. 11, p. 1022-9, Mar 17 1999. ISSN 0098-
7484. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/10086438 >.
6 WO, C. C. et al. Unreliability of blood pressure and heart rate to evaluate cardiac output
in emergency resuscitation and critical illness. Crit Care Med, v. 21, n. 2, p. 218-23, Feb
1993. ISSN 0090-3493. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/8428472 >.
7 SWAN, H. J. et al. Catheterization of the heart in man with use of a flow-directed
balloon-tipped catheter. N Engl J Med, v. 283, n. 9, p. 447-51, Aug 27 1970. ISSN 0028-
4793. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/5434111 >.
8
IENGHONG, K. et al. The diagnostic capabilities of the combined cardiac and lung
point of care ultrasound in shocked patients at the emergency department - Resourced
limited country. Eur J Radiol Open, v. 9, p. 100446, 2022. ISSN 2352-0477.
Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/36250194 >.
9 CIOZDA, W. et al. The efficacy of sonographic measurement of inferior vena cava
diameter as an estimate of central venous pressure. Cardiovasc Ultrasound, v. 14, n. 1,
29
p. 33, Aug 20 2016. ISSN 1476-7120. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/27542597 >.
10 JONES, A. E. et al. Randomized, controlled trial of immediate versus delayed goaldirected ultrasound to identify the cause of nontraumatic hypotension in emergency
department patients. Crit Care Med, v. 32, n. 8, p. 1703-8, Aug 2004. ISSN 0090-3493.
Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/15286547 >.
11 JENSEN, M. B. et al. Transthoracic echocardiography for cardiopulmonary monitoring
in intensive care. Eur J Anaesthesiol, v. 21, n. 9, p. 700-7, Sep 2004. ISSN 0265-0215.
Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/15595582 >.
12 BAUER, M. et al. Mortality in sepsis and septic shock in Europe, North America and
Australia between 2009 and 2019- results from a systematic review and meta-analysis.
Crit Care, v. 24, n. 1, p. 239, May 19 2020. ISSN 1466-609X. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/32430052 >.
13 VINCENT, J. L. et al. Frequency and mortality of septic shock in Europe and North
America: a systematic review and meta-analysis. Crit Care, v. 23, n. 1, p. 196, May 31
2019. ISSN 1466-609X. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/31151462 >.
14 AUDIMOOLAM, V. K. et al. Predicting Fluid Responsiveness in Acute Liver Failure: A
Prospective Study. Anesth Analg, v. 124, n. 2, p. 480-486, Feb 2017. ISSN 0003-2999.
15 LIU, V. et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA,
v. 312, n. 1, p. 90-2, Jul 02 2014. ISSN 1538-3598. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/24838355 >.
16 CECCONI, M. et al. Consensus on circulatory shock and hemodynamic monitoring.
Task force of the European Society of Intensive Care Medicine. Intensive Care Med, v.
40, n. 12, p. 1795-815, Dec 2014. ISSN 1432-1238. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/25392034 >.
17 KANJI, H. D. et al. Limited echocardiography-guided therapy in subacute shock is
associated with change in management and improved outcomes. J Crit Care, v. 29, n. 5,
p. 700-5, Oct 2014. ISSN 1557-8615. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/24857642 >.
18 EL-NAWAWY, A. A.; ABDELMOHSEN, A. M.; HASSOUNA, H. M. Role of
echocardiography in reducing shock reversal time in pediatric septic shock: a randomized
controlled trial. J Pediatr (Rio J), v. 94, n. 1, p. 31-39, Jan-Feb 2018. ISSN 0021-7557.
30
19 LANSPA, M. J. et al. Echocardiogram-guided resuscitation versus early goal-directed
therapy in the treatment of septic shock: a randomized, controlled, feasibility trial. J
Intensive Care, v. 6, p. 50, 2018. ISSN 2052-0492. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/30123511 >.
20 LAN, P. et al. Utilization of echocardiography during septic shock was associated with a
decreased 28-day mortality: a propensity score-matched analysis of the MIMIC-III
database. Ann Transl Med, v. 7, n. 22, p. 662, Nov 2019. ISSN 2305-5839. Disponível
em: < https://www.ncbi.nlm.nih.gov/pubmed/31930063 >.
21 LI, G. et al. [Clinical value of early liquid resuscitation guided by passive leg-raising test
combined with transthoracic echocardiography in patients with septic shock]. Zhonghua
Wei Zhong Bing Ji Jiu Yi Xue, v. 31, n. 4, p. 413-417, Apr 2019. ISSN 2095-4352.
Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/31109412 >.
22 LI, L. et al. Effect of focused cardiopulmonary ultrasonography on clinical outcome of
septic shock: a randomized study. J Int Med Res, v. 49, n. 5, p. 3000605211013176,
May 2021. ISSN 1473-2300. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/33990145 >.
23 YU, K. et al. Critical care ultrasound goal-directed versus early goal-directed therapy in
septic shock. Intensive Care Med, v. 48, n. 1, p. 121-123, Jan 2022. ISSN 1432-1238.
Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/34618187 >.
24 SEKIGUCHI, H. et al. Focused cardiac ultrasound in the early resuscitation of severe
sepsis and septic shock: a prospective pilot study. J Anesth, v. 31, n. 4, p. 487-493, Aug
2017. ISSN 1438-8359. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/28144779 >.
25 ARNOLDI, S. et al. Integrating Focused Cardiac Ultrasound Into Pediatric Septic Shock
Assessment. Pediatr Crit Care Med, v. 22, n. 3, p. 262-274, Mar 01 2021. ISSN 1529-
7535. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/33657611 >.
26 STICKLES, S. P. et al. The diagnostic accuracy of a point-of-care ultrasound protocol
for shock etiology: A systematic review and meta-analysis. CJEM, v. 21, n. 3, p. 406-
417, May 2019. ISSN 1481-8043. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/30696496 >.
27 BERG, I. et al. A Systemic Review on the Diagnostic Accuracy of Point-of-Care
Ultrasound in Patients With Undifferentiated Shock in the Emergency Department.
Cureus, v. 14, n. 3, p. e23188, Mar 2022. ISSN 2168-8184. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/35444920 >.
31
28 CHEN, Z. Ultrasound-guided fluid resuscitation versus usual care guided fluid
resuscitation in patients with septic shock: a systematic review and meta-analysis.
HAN, X.;LIU, Y., et al. China: Emergency and critical care medicine 2023.
29 VIEILLARD-BARON, A. Septic cardiomyopathy. Ann Intensive Care, v. 1, n. 1, p. 6,
Apr 13 2011. ISSN 2110-5820.
30 HABIMANA, R. et al. Sepsis-induced cardiac dysfunction: a review of pathophysiology.
Acute Crit Care, v. 35, n. 2, p. 57-66, May 2020. ISSN 2586-6060. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/32506871 >.
31 PARKER, M. M. et al. Profound but reversible myocardial depression in patients with
septic shock. Ann Intern Med, v. 100, n. 4, p. 483-90, Apr 1984. ISSN 0003-4819.
Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/6703540 >.
32 GERI, G. et al. Cardiovascular clusters in septic shock combining clinical and
echocardiographic parameters: a post hoc analysis. Intensive Care Med, v. 45, n. 5, p.
657-667, May 2019. ISSN 0342-4642.
33 HJORTRUP, P. B. et al. Restricting volumes of resuscitation fluid in adults with septic
shock after initial management: the CLASSIC randomised, parallel-group, multicentre
feasibility trial. Intensive Care Med, v. 42, n. 11, p. 1695-1705, Nov 2016. ISSN 1432-
1238. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/27686349 >.
34 SILVERSIDES, J. A. et al. Conservative fluid management or deresuscitation for
patients with sepsis or acute respiratory distress syndrome following the resuscitation
phase of critical illness: a systematic review and meta-analysis. Intensive Care Med, v.
43, n. 2, p. 155-170, Feb 2017. ISSN 1432-1238. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/27734109 >.
35 MEYHOFF, T. S. et al. Restriction of Intravenous Fluid in ICU Patients with Septic
Shock. N Engl J Med, v. 386, n. 26, p. 2459-2470, Jun 30 2022. ISSN 1533-4406.
Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/35709019 >.
36 MOHER, D. et al. Preferred reporting items for systematic reviews and meta-analyses:
the PRISMA statement. PLoS Med, v. 6, n. 7, p. e1000097, Jul 21 2009. ISSN 1549-
1676. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/19621072 >.
37 PAGE, M. J. et al. PRISMA 2020 explanation and elaboration: updated guidance and
exemplars for reporting systematic reviews. BMJ, v. 372, p. n160, Mar 29 2021. ISSN
1756-1833. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/33781993 >.
32
38 ATKINSON, P. R. et al. Does Point-of-Care Ultrasonography Improve Clinical
Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An
International Randomized Controlled Trial From the SHoC-ED Investigators. Ann
Emerg Med, v. 72, n. 4, p. 478-489, Oct 2018. ISSN 1097-6760. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/29866583 >.
39 KIM, D. W. et al. Diagnostic Accuracy of Ultrasonographic Respiratory Variation in the
Inferior Vena Cava, Subclavian Vein, Internal Jugular Vein, and Femoral Vein Diameter
to Predict Fluid Responsiveness: A Systematic Review and Meta-Analysis. Diagnostics
(Basel), v. 12, n. 1, Dec 27 2021. ISSN 2075-4418. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/35054215 >.
40 ALHABASHY, W. S. Echocardiography-Guided HemodynamicManagement of Severe
Sepsis and Septic Shock inAdults: A Randomized Controlled Trial. SHALABY, O. M.
Tanta University, Egypt: Research Square 2020.
41 AFANDY, M. E. Transthoracic echocardiographic versus cardiometry derived
indices in management of septic patients Egypt: Egyptian Journal of
Anaesthesia 2020.
42 LIN, Y. M. et al. Association of sepsis-induced cardiomyopathy and mortality: a
systematic review and meta-analysis. Ann Intensive Care, v. 12, n. 1, p. 112, Dec 13
2022. ISSN 2110-5820. Disponível em: <
https://www.ncbi.nlm.nih.gov/pubmed/36513882 >.
33
Chapter seven: Apendix A.
Authors:
Keith Killu, MD1
. Principal author
Institutional Affiliation: Clinical Associate Professor of Medicine
University of Southern California, Keck School of Medicine
2020 Zonal Ave.
IRD #720, Los Angeles, CA 90033, USA
Tel: 646-2847825
Email: keith.killu@med.usc.edu
Contribution: Research, article review and manuscript writing and editing. Guarantor of the review
Cecilia Patino-Sutton2
, MD, MEd, PhD
Institutional Affiliation: Associate Professor of Population and Public Health Sciences
(Educational Scholar)
University of Southern California, Keck School of Medicine
Email: patinosu@usc.edu
Contribution: Co-Author. Research, article review and manuscript writing and editing. Overall
project mentor. Guarantor of the review
Victoria Kristence Cortessis2
, PhD
Institutional Affiliation: Professor of Population and Public Health Sciences
University of Southern California, Keck School of Medicine
Email: cortessi@usc.edu
Contribution: Epidemiologist, Biostatistics. Research, article review and assist in manuscript
writing and editing. Guarantor of the review
Lynn Kysh3
, MLIS
Institutional Affiliation: Clinical and research Librarian
University of Southern California, Keck School of Medicine
Email: lkysh@chla.usc.edu
Contribution: Librarian. Research, article review and assist in manuscript writing and editing.
Richard Castriotta1
, MD
Institutional Affiliation: Professor of Clinical Medicine
University of Southern California, Keck School of Medicine
Email: Richard.Castriotta@med.usc.edu
Contribution: Content expert. Research, article review and assist in manuscript writing and
editing. Guarantor of the review
John Oropello4
, MD
Institutional Affiliation: Professor of Surgery and Medicine
Icahn School of Medicine at Mount Sinai Hospital
Email: john.oropello@mountsinai.org
Contribution: Content expert. Research, article review and assist in manuscript writing and
editing. Guarantor of the review
34
Luis Huerta1
, MD
Institutional Affiliation: Clinical Assistant Professor of Medicine
University of Southern California, Keck School of Medicine
Email: luis.huerta@med.usc.edu
Contribution: Content expert. Research, article review and assist in manuscript writing and
editing. Guarantor of the review
Engracia, Dominic1
, MD
Institutional Affiliation: Fellow in training of Pulmonary and critical carre medicine
University of Southern California, Keck School of Medicine
Email: dominic.engracia@med.usc.edu
Contribution: Research, article review and assist in manuscript writing and editing.
Merchant, Karim1
,MD
Institutional Affiliation: Fellow in training of Pulmonary and critical carre medicine
University of Southern California, Keck School of Medicine
Email: karim.merchant@med.usc.edu
Contribution: Research, article review and assist in manuscript writing and editing.
1 University of Southern California, Keck School of Medicine, Pulmonary Critical Care and Sleep division,
Department of Internal Medicine
2 University of Southern California, Keck School of Medicine, Department of Population and Public Health
Sciences
3 Norris Medical Library, Keck School of Medicine of the University of Southern California.
4 The Ichan School of Medicine at the Mount Sinai Hospital.
Abstract (if available)
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Asset Metadata
Creator
Killu, Keith
(author)
Core Title
The association between Echocardiography use in the Intensive Care Unit and 28-day mortality among patients with septic shock: a systematic review
School
Keck School of Medicine
Degree
Master of Science
Degree Program
Public Health
Degree Conferral Date
2023-12
Publication Date
12/01/2023
Defense Date
11/30/2023
Publisher
Los Angeles, California
(original),
University of Southern California
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Tag
echocardiography,mortality outcome,OAI-PMH Harvest,point of care echocardiography,septic shock
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theses
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English
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Electronically uploaded by the author
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Advisor
Patino-Sutton, Cecilia Patino-Sutton (
committee chair
), Castriotta, Richard (
committee member
), Huerta, Luis (
committee member
), Oropello, John (
committee member
)
Creator Email
keith.killu@med.usc.edu,killukei@hotmail.com
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https://doi.org/10.25549/usctheses-oUC113781072
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Tags
echocardiography
mortality outcome
point of care echocardiography
septic shock