PAC vs TOE in Shock

OVERVIEW

  • there are many differences between the use of TOE vs PAC in the management of shock
  • indications depend on specific information desired and local expertise
  • potential information obtained must be weighed against risk
  • if standard precautions used mortality and morbidity with either techniques is rare

PRACTICAL ASPECTS

TOE

  • inserted orally
  • can only be inserted in anaesthetised patients
  • useful in unstable patients (diagnosis in unstable aortic dissection patients)
  • interpretation often very subjective
  • not all data continuous (only one view @ a time)
  • expensive equipment and maintenance
  • may distract from other important aspects of management

PAC

  • invasive (all risks of CVL insertion)
  • patient can be awake
  • takes longer to insert than TOE

INFORMATION PROVIDED

TOE

  • systolic function (fractional shortening of LV, EF, fractional area of contraction)
  • SV
  • Q
  • pressures (PAP in presence of TR, RSVP +LSVP in presence of VSD, PASP, LAP, LVEDP)
  • valve areas
  • calculation of regurgitant volumes and fractions
  • intracardiac shunt fraction
  • pericardial disease (tamponade)

PAC

  • Q (thermodilution technique applied or continuous monitoring)
  • PAP
  • SvO2
  • RAP
  • derived values = SVR, SVRI, SV, SVI, PVR, PVRI, Left Ventricular Stroke Work Index

DATA INTERPRETATION

TOE – data interpretation affected by

  • user inexperience (steep learning curve)

PAC – thermodilution accuracy affected by

  • cardiac shunt
  • TR and MR
  • variation in temperature from a variety of sources
  • IPPV

SAFETY AND COMPLICATIONS

TOE

  • oesophageal ulceration +/- perforation
  • sore throat
  • airway obstruction
  • displacement of ETT
  • orophayrngeal/dental trauma
  • cardiac aneurysm rupture
  • sympathetic stimulation
  • infection

PAC

  • arrhythma (heart block)
  • infection
  • knotting
  • pulmonary infarction
  • hypotension
  • hypoxia
  • PA rupture
  • air embolism
  • in large trials not shown to produce benefit
  • limited sensitivity for detecting myocardial ischaemia
  • PAWP only intermittent measurement

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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