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Circulatory shock is a life-threatening condition responsible for inadequate tissue perfusion. The objectives of hemodynamic monitoring in this setting are multiple: identifying the mechanisms of shock (hypovolemic, distributive, cardiogenic, obstructive); choosing the adequate therapeutic intervention, and evaluating the patient's response. Echocardiography is proposed as a first line tool for this assessment in the intensive care unit. As compared to trans-thoracic echocardiography (TTE), trans-esophageal echocardiography (TEE) offers a better echogenicity and is the best way to evaluate deep anatomic structures. The therapeutic implication of TEE leads to frequent changes in clinical management. It also allows depicting sources of inaccuracy of thermodilution-based hemodynamic monitoring. It is a semi invasive tool with a low rate of complications. The first step in the hemodynamic evaluation of shock is to characterize the mechanisms of circulatory failure among hypovolemia, vasoplegia, cardiac dysfunction, and obstruction. Echocardiographic evaluation includes evaluation of LV systolic and diastolic function, as well as RV function, pericardium, measure of stroke volume and cardiac output, and evaluation of hypovolemia and fluid responsiveness. TEE can be used as a semi-continuous monitoring tool and can be repeated before and after therapeutic interventions (vasopressors, inotropes, fluid therapy, specific treatment such as pericardial effusion evacuation) to evaluate efficacy and tolerance of therapeutic interventions. In conclusion, TEE plays an important role in the management of circulatory failure when TTE is not enough to answer to the questions, although it is not a continuous tool of monitoring. TEE results must be integrated in a global evaluation, the first step being clinical examination. Whether TEE-directed therapy and close hemodynamic monitoring of shock has an impact on outcome remains debated.

Hemodynamic monitoring using trans esophageal echocardiography in patients with shock