Skip to main content
Article thumbnail
Location of Repository

Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients

By Graham Mowatt, G. Houston, Rodolfo Andrés Hernández, Robyn De Verteuil, Cynthia Mary Fraser, Brian Cuthbertson and Luke David Vale

Abstract

Objectives: To assess the effectiveness and costeffectiveness of oesophageal Doppler monitoring (ODM) compared with conventional clinical assessment and other methods of monitoring cardiovascular function. Data sources: Electronic databases and relevant websites from 1990 to May 2007 were searched. Review methods: This review was based on a systematic review conducted by the US Agency for Healthcare Research and Quality (AHRQ), supplemented by evidence from any additional studies identified. Comparator interventions for effectiveness were standard care, pulmonary artery catheters (PACs), pulse contour analysis monitoring and lithium or thermodilution cardiac monitoring. Data were extracted on mortality, length of stay overall and in critical care, complications and quality of life. The economic assessment evaluated strategies involving ODM compared with standard care, PACs, pulse contour analysis monitoring and lithium or thermodilution cardiac monitoring. Results: The AHRQ report contained eight RCTs and was judged to be of high quality overall. Four comparisons were reported: ODM plus central venous pressure (CVP) monitoring plus conventional assessment vs CVP monitoring plus conventional assessment\ud during surgery; ODM plus conventional assessment vs CVP monitoring plus conventional assessment during surgery; ODM plus conventional assessment vs conventional assessment during surgery; and ODM plus CVP monitoring plus conventional assessment vs CVP monitoring plus conventional assessment postoperatively. Five studies compared ODM plus CVP monitoring plus conventional assessment with CVP monitoring plus conventional assessment during surgery. There were fewer deaths [Peto odds ratio (OR) 0.13, 95% CI 0.02–0.96], fewer major complications (Peto OR 0.12, 95% CI 0.04–0.31), fewer total complications (fixed-effects OR 0.43, 95% CI 0.26–0.71) and shorter length of stay (pooled estimate not presented, 95% CI –2.21 to –0.57) in the ODM group. The results of the meta analysis of mortality should be treated with caution owing to the low number of events and low overall number of patients in the combined totals. Three studies compared ODM plus conventional assessment with conventional assessment during surgery. There was no evidence of a difference in mortality (fixed-effects OR 0.81, 95% CI 0.23–2.77). Length of hospital stay was shorter in all three studies in the ODM group. Two studies compared ODM plus CVP monitoring plus conventional assessment vs CVP monitoring plus conventional assessment in critically ill patients. The patient groups were quite different (cardiac surgery and major trauma) and neither study, nor a meta-analysis, showed a statistically significant difference in mortality (fixed-effects OR 0.84, 95% CI 0.41–1.70). Fewer patients in the ODM group experienced complications (OR 0.49, 95% CI 0.30–0.81) and both studies reported a statistically significant shorter median length of hospital stay in that group. No economic evaluations that met the inclusion criteria were identified from the existing literature so a series of balance sheets was constructed. The results show that ODM strategies are likely to be cost-effective. Conclusions: More formal economic evaluation would allow better use of the available data. All identified studies were conducted in unconscious patients. However, further research is needed to evaluate new ODM probes that may be tolerated by awake patients. Given the paucity of the existing economic evidence base, any further primary research should include an economic evaluation or should provide data suitable for use in an economic model.The Health Services Research Unit and the Health Economics Research Unit are both core funded by the Chief Scientist Office of the Scottish Government Health Directorate.Peer reviewedPublisher PD

Topics: Cost-benefit Analysis, Critical Care, Echocardiography, Transesophageal, Treatment Outcomes, RD Surgery
Publisher: National Institute for Health Research
Year: 2009
DOI identifier: 10.3310/hta13070
OAI identifier: oai:aura.abdn.ac.uk:2164/275
Journal:
Download PDF:
Sorry, we are unable to provide the full text but you may find it at the following location(s):
  • http://hdl.handle.net/2164/275 (external link)
  • http://dx.doi.org/10.3310/hta1... (external link)
  • Suggested articles

    Citations

    1. (#8 AND #21)#24. (cardioq) or (teco)
    2. 2007
    3. 2009
    4. 2009 Queen’s
    5. 2009 Queen’s Printer and Controller of
    6. 2009 Queen’s Printer and Controller of HMSO. All rights reserved.
    7. 2009 Queen’s Printer and Controller of HMSO. All rights reserved. 111 DOI: 10.3310/hta13070 Health Technology
    8. 2009 Queen’s Printer and Controller of HMSO. All rights reserved. 85 DOI: 10.3310/hta13070 Health Technology Assessment 2009; Vol. 13: No. 7 Assessor initials: GM Study identifier: AHRQ 20076 (Surname of first author and
    9. 2009 Queen’s Printer and Controller of HMSO. All rights reserved. 97
    10. 52 flow monitored protocol for optimisation of circulatory status after cardiac surgery. doi
    11. 9. Were the conclusions made by the author(s)
    12. 91 DOI: 10.3310/hta13070 Health Technology Assessment 2009; Vol. 13: No. 7 Study Stroke volume FTc Cardiac
    13. (2004). A guide for manufacturers and sponsors.
    14. A review by Fitzpatrick R, Shortall E, Sculpher M,
    15. (2006). activity guidance and requirements. London: Department of Health;
    16. Angus DC. Protocolized resuscitation with esophageal Doppler monitoring may improve
    17. Barber J, Clayton W, Currell R, Fleming K, Garner P, et al. Volume 9, 2005 No. 1 Randomised controlled multiple treatment
    18. Bower DJ, Brebner JA, Cairns JA, Grant AM, McKee L. Volume 2,
    19. Buxton M, Green C, Coulson D, Raftery J. Volume 12, 2008 No. 1 A systematic review and economic model of switching from nonglycopeptide to glycopeptide antibiotic prophylaxis for surgery. By Cranny G, Elliott
    20. By Bankhead CR, Brett J, Bukach C, Webster P, Stewart-Brown S, Munafo M, et al. Volume 8, 2004 No. 1 What
    21. By Dretzke J, Frew E, Davenport C, Barlow J, Stewart-Brown S, Sandercock J, et al.
    22. By Hewison J, doi
    23. By Roderick P, Davies R, Raftery J, Crabbe D, Pearce R, Bhandari P, et al.
    24. By Sanderson D, Wright D, Acton C, Duree D. Volume 6,
    25. cardiac
    26. Cardiac output measurement during cardiac surgery: esophageal Doppler versus pulmonary artery catheter. doi
    27. Cardiac output measurement using the transesophageal Doppler method is less accurate than the thermodilution method when changing Paco(2). Anesth Analg 2005;101(6):1597–601. Seoudi HM, Perkal MF, doi
    28. Chalmers RJG, Li Wan Po A, Williams HC. Volume 5,
    29. CINAHL (1990 to May week 2 2007) Ovid Multifile Search – URL: http://gateway.ovid. com/athens ((oesophageal or esophageal
    30. Cipolla
    31. Clinical evaluation of the HemoSonic monitor in cardiac surgical patients in the ICU.
    32. Clinical Pharmacology, University of Liverpool Deputy Director, Professor Jon Nicholl, Director, Medical Care Research Unit, University of Sheffield
    33. Cochrane Library (Issue 2, 2007) URL: http://www3.interscience.wiley.com/cgi-bin/ mrwhome/106568753/HOME (oesophageal NEAR/5 (doppler
    34. Colbert S, O’Hanlon DM, Duranteau J, Ecoffey C. Cardiac output doi
    35. Collins S, Girard F, Boudreault D, Chouinard P, Normandin L, Couture P et al. Esophageal Doppler and thermodilution doi
    36. Cranny G, Iglesias CP, Hawkins K, Cullum NA, et al.
    37. D, Cummins C, Bayliss S, Sandercock J, Burls A. Volume 13, 2009 No. 1 Deferasirox for the treatment of iron overload associated with regular
    38. Dark PM, Singer M. The validity of trans-esophageal Doppler ultrasonography as a doi
    39. Descending aortic blood flow and cardiac output: a clinical and experimental study of continuous oesophageal echo–Doppler flowmetry. Acta Anaesthesiol Scand 2001;45(2):180–7. Sawai doi
    40. DP. Extravascular lung water measurements and hemodynamic monitoring in the critically ill: bedside alternatives doi
    41. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care 2005;9(6):R687–93. Improving access to cost-effectiveness information 54.
    42. Echocardiography, Transesophageal/3. or/1–34. exp echocardiography,
    43. Echocardiography, Transesophageal/3. or/1–34. exp echocardiography, doppler/5. doppler echocardiograph/6. doppler flowmeter/7. Appendix 3 80 ultrasonography, doppler/8. or/5–89. (oesophageal or esophageal or 10. intra?esophageal or
    44. Ellis JE. Con: pulmonary artery catheters are not routinely indicated in patients undergoing elective abdominal aortic reconstruction. J Cardiothorac Vasc doi
    45. esophageal AND (DOPPLER OR 3. ULTRASON*)) (intra AND esophageal AND (DOPPLER OR 4. ULTRASON*)) (intra AND oesophageal AND (DOPPLER OR 5. ULTRASON*)) (trans AND oesophageal
    46. Esophageal Doppler and thermodilution are not interchangeable for determination of cardiac output. doi
    47. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial.
    48. (2001). for health care decision making: the NHS Economic Evaluation Database. doi
    49. Hemodynamic 35. monitoring of organ donors: a novel use of the esophageal echo-Doppler probe. Am Surg 2006;72(6):500–4. Collins
    50. Hemodynamic measurements after cardiac surgery: transesophageal Doppler versus pulmonary artery catheter. doi
    51. hemodynamic monitoring: a minimally invasive alternative. AACN Clin Issues 2003;14(2):220–31. doi
    52. (2005). Information Services Division R040. 31. Specialty group costs – inpatients in acute specialties.
    53. Intraoperative 22. intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. doi
    54. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. doi
    55. J Anaesthesiol 2004;21(7):581–3. doi
    56. J. Cardiac output monitoring: need for improvement? doi
    57. JW, Venn RM. Perioperative fluid volume optimization following proximal femoral fracture. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003004. DOI: 10.1002/14651858.CD003004.pub2. doi
    58. (2005). Karampinis A et al. Esophageal Doppler (ODM II) improves intraoperative hemodynamic monitoring during laparoscopic surgery. Surg Laparosc Endosc Percutan Tech doi
    59. Krishnamurthy B, McMurray TJ, McClean E. The perioperative use of the oesophageal Doppler monitor in patients doi
    60. Levinson MM. Intraoperative monitoring during
    61. Li FH, Hao J, Xia JG Li HL, Fang H. Hemodynamic analysis of
    62. M : 1 1; F : 9 C on tr ol : M : 9 ; F : 1 1 Ty pe o f s ur ge ry : c ol or ec ta l In cl us io n
    63. Matthews P.
    64. (2005). Methods for the economic evaluation of health care programmes. 3rd edn.
    65. Monitoring of peri-operative fluid administration by individualized goal-directed therapy. doi
    66. Nakamura S. Hemodynamics of
    67. NHS EED (May 2007) URL: www.crd.york.ac.uk/crdweb/
    68. Noninvasive monitoring of cardiac output in critically ill patients using transesophageal Doppler. Am J Respir Crit Care Med 1998;158(1):77–83. Chandan GS, Hull JM. Incorrectly placed 49. doi
    69. oesophageal Doppler probe. Anaesthesia 2004;59(7):723. Reducing length of stay: case studies.
    70. Optimization of cardiac preload during laparoscopic donor nephrectomy: a preliminary study of central venous pressure versus esophageal Doppler monitoring. Surg Endosc 2004;18(3):412–16. Iregui doi
    71. (1213). OR ULTRASON*)) (trans AND esophageal AND (DOPPLER OR #7. ULTRASON*)) (transesophageal AND (DOPPLER OR #8. ULTRASON*)) (intraesophageal AND (DOPPLER OR #9. ULTRASON*)) #1 doi
    72. peri-operative use of the oesophageal Doppler monitor in patients undergoing coronary artery revascularisation. A comparison with the continuous cardiac output monitor. Anaesthesia 1997;52(7):624– 9. Moxon doi
    73. (2004). Perioperative fluid volume optimization following proximal femoral fracture. Cochrane Database of Systematic Review: doi
    74. Perioperative plasma 20. volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. doi
    75. Physicians’ estimates of cardiac index and intravascular volume based on clinical assessment versus transesophageal Doppler measurements obtained by critical care nurses.
    76. (2005). Quality of life before and after intensive care. Anaesthesia doi
    77. (2009). Queen’s Printer and Controller of HMSO. All rights reserved. 53 DOI:
    78. (2009). Queen’s Printer and Controller of HMSO. All rights reserved. 55 DOI:
    79. (2009). Queen’s Printer and Controller of HMSO. All rights reserved. 57 DOI:
    80. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after doi
    81. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. doi
    82. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. doi
    83. Rocen M, Prikryl P, Zenkner W, Machalova O, Vychodil
    84. Science Citation Index (1990 to 1 July 2007) ISI Web of Knowledge – URL:
    85. Science Citation Index (1990 to 20 May 2007) BIOSIS (1990 to17 May 2007) ISI Web of Knowledge – URL: http://wok.mimas. ac.uk/ TS=(oesophageal SAME (doppler or
    86. (2007). Scottish health service costs.29. ISD Scotland;
    87. Technology Assessment 2009; Vol. 13: No. 7 No. 19 A rapid and systematic review and economic evaluation of the clinical and
    88. The esophageal Doppler monitor in mechanically ventilated surgical patients: does it work?
    89. Turner D, et al. Volume 7, 2003 No. 1 How important are comprehensive literature searches and the
    90. (2004). Using the oesophageal doppler monitor in elective colorectal surgery [poster presentation]. Annual Meeting of Wessex Anaesthetists in Training.
    91. van der Hoeven J, Olsman J. Hemodynamic monitoring in the critically ill patient. Neth J Med 2000;57(3):71–3. doi
    92. Vol. doi
    93. Walley KR. Comparison of transesophageal echocardiographic, Fick and thermodilution cardiac output in crtitically ill patients. doi
    94. (2007). York: Centre for Reviews and Dissemination;

    To submit an update or takedown request for this paper, please submit an Update/Correction/Removal Request.