Letter 1 Dr. Paul W. Corey


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Letter 1 Dr. Paul W. Corey

  1. 1. James C. Eisenach, M.D. Editor-in-Chief RE: 200810121 - Esophageal Doppler is an Important Part of Perioperative Fluid Management (RE: Chappell J, et al. 2008;109:723-40) Dear Dr. Eisenach, I would like to take this opportunity to thank you for the incredibly valuable service you perform as the editor and chief of Anesthesiogy. Thank you for your careful reading of my letter and the article itself. The role of TEE in the management of perioperative fluid administration, in my humble opinion as explained in my original letter and below, is covered incompletely and as such is a disservice to our specialty. This incomplete coverage minimizes an extremely powerful tool that fixes a fundamental flaw in our understanding of hemodynamics. This tool also provides a means to make A Rational Approach to Perioperative Fluid Management a reality. Please take the 2 or 3 minutes necessary to read this. I need your help. I have been a dedicated cardiac anesthesiologist at a tertiary cardiac center in San Diego for 28 years. We have been using dedicated TEE in all our heart rooms since 1987 and esophageal Doppler monitors in all our operating rooms since 1999. I would like to mention a few observations. The large multipurpose TEE machines do not allow us to follow hemodynamics in a continuous real time fashion. We can calculate snapshot hemodynamics in a time consuming process. This is not beat to beat real time management. The esophageal Doppler monitors are different and have distinct advantages.
  2. 2. The opportunity to measure flow by multipurpose TEE machines is limited for the majority of patients by cost issues. The esophageal Doppler is readily applicable to all intubated patients and can be used in awake unintubated patients as well. Disposable probes that can be used for up to 10 days in a single patient cost $170. Most importantly, we have no fundamental understanding of flow in the majority of the 35 million patients that we care for each year. If we use the esophageal Doppler to understand flow we can improve clinical outcomes. The evidence is substantial, unique to the esophageal Doppler, and referenced in my original letter. Without flow it is impossible to understand the simplest of hemodynamic relationships, Pressure = Flow x Resistance. We can not understand a 3 variable equation with only one variable. We need to know 2 of the variables to get an understanding of the equation. Adding heart rate and urine output to blood pressure will still allow no basic hemodynamic understanding. This means we have no understanding of hemodynamics in the majority of the 35 million patients we care for each year. This is an astonishing fundamental flaw in our knowledge base and in the way we care for our patients. Without this understanding we unknowingly bring patients to recovery areas every day with acceptable blood pressures and heart rates with unacceptable hemodynamics. We do not recognize this unacceptability until the multiple compensatory mechanisms that maintain BP are exhausted and the BP deteriorates. We are then reacting to an abnormal situation as opposed to actually knowing the hemodynamics in real time and anticipating the development of the abnormal situation and taking care of it before it becomes severely abnormal or unstable.
  3. 3. Even in normotensive patients, we can have very low flows and high resistances and are blind to this without flow measurements. This is not a good situation for patients and not a good situation for a profession that is supposed to know what it is doing. And, what about hypotensive patients? Do we need increased preload, do we need a vasopressor, an inotrope, a combination? We guess. We make mistakes and many times are completely unaware of these mistakes because we see the BP move in the direction we want but are unaware of the underlying hemodynamics which can change in ways that may be detrimental to outcomes. The esophageal Doppler takes away the guess work, so we can specifically understand and deal with the hemodynamic problem. The ED brings to our specialty an incredible opportunity to be the fixers of a fundamental flaw, reap the benefits for our patients and increase our stature as providers of high quality care. As an aside, here are the tenants of one of our QI projects. Point 4 is particularly important to our society. 1. With the addition of cardiac output monitoring we gain a fundamental understanding of the hemodynamic status of each patient that we care for. 2. If we understand the hemodynamics of each patient we can optimize them. 3. If we optimize the hemodynamics of each patient in our OR’s and ICU’s we can decrease hospital length of stay, health care costs and patient complications. 4. If we are proactive in the enhancement of quality care and create cost efficiencies we dramatically increase our value. This translates into stronger and more secure relationships with our hospitals, insurers, government, medical colleagues, patients, and community, both regionally and nationally.
  4. 4. CMS has seen the evidence base and value of the esophageal Doppler. It has seen the potential of great cost savings for the healthcare system that it can provide. CMS has said that use of esophageal Doppler is “reasonable and necessary” and further that its use be covered for “monitoring of cardiac output with the esophageal Doppler for ventilated ICU patients and operative patients requiring fluid optimization”. We as a society need to understand hemodynamics in all the patients we care for and with this understanding properly assure that all the components of flow are acceptable. We currently do things backwards. We assure that the pressure is acceptable and assume the flow and resistance are as well. We all know this is wrong. What we need to do to fix this fundamental flaw is to assure that the flow is acceptable (acceptable preload and contractility) and the resistance is acceptable. Then the pressure will follow by default. This is the simple paradigm shift that will fix our fundamental flaw and improve outcomes. The esophageal Doppler enables us to fix this problem. Adjusting the preload properly is just a small part of what one can accomplish with this technology and why ‘the esophageal Doppler is an important part of Perioperative Fluid Management” as stated in my original letter. I am interested in flow and interested in fixing this problem. I have been a consultant to companies that make ED’s because it allows us to understand hemodynamics at a fundamental level and enables us to know what we are doing with the various therapeutic modalities we use to care for the majority of our patients.
  5. 5. First we have to realize and accept the important fact that we have no understanding of flow and the components of flow in the majority of patients we care for. Then we have to get that understanding and use it to improve outcomes as done in all the randomized controlled trials referenced in my original letter. Industry will then hop on board and will evolve newer and better modalities. They will respond when we show them the need. But frankly, most of us are unconscious about this problem. It’s time to wake up, to emerge from this unconsciousness. We need to be aware of this tool and need to correct this flaw. Flow is important and neglected. I know your time is valuable. This is important. Please take the time to respond. Please feel free to share this with any of your clinical colleagues that may be able to help. How can we accomplish this? I want to see this flaw fixed before I retire. It will elevate our specialty a quantum level. Sincerely, Paul W. Corey, MD. Director, Cardiovascular Anesthesia Sharp Memorial Hospital San Diego, CA.