Rescue Echocardiography/Ultrasonography in the Management of Combined Cardiac Surgical and Medical Patients in a Cardiac Intensive Care Unit

A Multi-Country Survey on the Availability of Intraoperative Use of Echocardiography for Noncardiac Surgery

BACKGROUND

This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide.

METHODS

An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022.

RESULTS

1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers.

CONCLUSIONS

Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) cannula malposition identified with point-of-care ultrasound

BACKGROUND

Point-of-care ultrasound (POCUS) has become a mainstay in the evaluation of critically ill patients in the intensive care unit (ICU). ECMO patients are susceptible to complications during prolonged ICU stay, including cannula malposition, which has deleterious consequences. Although the literature surrounding utility of ultrasound on ECMO patients is expansive, direct comparison between radiographic imaging versus ultrasound for identification of cannula malposition is lacking.

CASE PRESENTATION

The authors identified four patients with cannula malposition discovered through POCUS that was missed on routine radiographic imaging. Identification and correction of malposition changed their ECMO course.

CONCLUSION

This case series is the first in literature demonstrating that ultrasound may be superior to radiographic images for ECMO cannula malposition. Further investigation into this subject is warranted.

Past and Present of Point-of-Care Ultrasound (PoCUS): A Narrative Review

This article aims to conduct a literature review to gain insight into point-of-care ultrasound (PoCUS). PoCUS is a rapid, accurate, non-invasive, and radiation-free imaging modality that can be used in stable and unstable patients. PoCUS can be performed parallel to physical examination, resuscitation, and stabilization; repeated exams in critical patients are essential for improving sensitivity. The review highlights how PoCUS, which was initially used to detect free intraperitoneal fluid in trauma patients, has developed into a life-saving diagnostic tool that could be utilized by treating physicians during various stages of diagnosis, resuscitation, operation, and postoperative critical care when managing sick patients. The review also notes the barriers to the widespread uptake of PoCUS in general internal medicine and the recent commercial availability of "pocket" or handheld probes that have made PoCUS more readily available. This review concludes that adopting a focused binary decision-making approach can maximize PoCUS's value in many clinical settings, including emergency departments, intensive care units, and operation theatres. Overall, the review emphasizes the importance of awareness of common indications, limitations, and strengths of this evolving and promising technology to determine its future trajectory: Providing comprehensive PoCUS training within internal medicine curriculums and supporting trainers to do so.

Point-of-Care Ultrasound for the Diagnosis of Frequent Cardiovascular Diseases: A Review

Point-of-care ultrasound (POCUS) has emerged as an indispensable diagnostic tool in cardiology, particularly within the emergency department. This narrative synthesis provides a comprehensive exploration of POCUS applications in cardiovascular diseases, elucidating its multifaceted roles and addressing challenges. The review delves into the technical attributes of POCUS, emphasizing its non-invasive nature, radiation-free qualities, and suitability for non-radiologists. It navigates through educational strategies, stressing the importance of structured programs for the seamless integration of POCUS into clinical practice. Highlighting its efficacy, the synthesis discusses POCUS applications in various scenarios such as dyspnea, chest pain, cardiac arrest, aortic dissection, pericardial effusion, and pulmonary embolism. Beyond acute care, the review explores the role of POCUS in outpatient and inpatient settings, focusing on chronic and acute heart failure, valvular heart diseases, and more. Acknowledging operator-dependent challenges and the need for continuous education, the review underscores the transformative potential of POCUS across diverse healthcare settings. This narrative synthesis accentuates POCUS as a valuable and versatile diagnostic tool in cardiology, offering efficiency, safety, and cost-effectiveness. Despite challenges, POCUS stands out as a transformative addition to clinical practices, poised to enhance patient outcomes and reshape the landscape of cardiovascular diagnostics.

Comparison of visual estimation and quantitative measurement of left ventricular ejection fraction in untrained perioperative echocardiographers

BACKGROUND

Perioperative evaluation of the left ventricular systolic function is essential information to help diagnose and manage life-threatening perioperative emergencies. Although quantifying the left ventricular ejection fraction (LVEF) is recommended to determine the left ventricular function, it may not always be feasible in emergency perioperative settings. This study compared the visual estimation of LVEF (eyeballing) by noncardiac anesthesiologists with the quantitative LVEF measured using a modified Simpson's biplane method.

METHODS

Transesophageal echocardiographic (TEE) studies of 35 patients were selected and 3 different echocardiographic views (the mid-esophageal four chamber view, the mid-esophageal two chamber view, and the transgastric mid-papillary short axis view) were recovered from each study and displayed in random order. Two cardiac anesthesiologists certified in perioperative echocardiography independently measured LVEF using the modified Simpson method and categorized LVEF into five grades: hyperdynamic LVEF, normal, mildly reduced LVEF, moderately reduced LVEF and severely reduced LVEF. Seven noncardiac anesthesiologists with limited experience in echocardiography also reviewed the same TEE studies and estimated the LVEF and graded LV function. The precision of the LV function classification and the correlation between visual estimation of LVEF and quantitative LVEF were calculated. The agreement of measurements between the two methods was also assessed.

RESULTS

Pearson's correlation between the LVEF estimated by the participants and the quantitative LVEF using the modified Simpson method was 0.818 (p < 0.001). Of a total of 245 responses, 120 (49.0%) responses were correct grading of the LV function. Participants were able to classify the LV function more accurately in the LV function grades 1 and 5 (65.3%). The 95% level of agreement of the Bland-Altman method was - 11.3-24.5. -21.9-22.6, - 23.1-26.5, - 20.5-22.0 and - 26.6-11.1 for LV grade 1 to 5, respectively.

CONCLUSION

Visual estimation of LVEF in perioperative TEE has acceptable accuracy in untrained echocardiographers and can be used for rescue TEE.

The Frequency of POCUS in the Treatment of Sepsis in the Emergency Department: A Retrospective Cohort Study

Background: Point of care ultrasound (POCUS) is ubiquitous in the modern emergency department (ED). POCUS can be helpful in the management of patients with sepsis in many ways including determining the cause of sepsis, assessing fluid status, guiding resuscitation, and performing procedures. However, the frequency and manner in which POCUS is incorporated into the care of septic patients in community emergency medicine remains unclear. Objective: To evaluate POCUS frequency and exam types used in the care of patients with sepsis in two community EDs in Southern California. Methods: We performed a retrospective analysis of 5,264 ED visits with a diagnosis of sepsis at two community emergency departments between January 2014 and December 2018. Patients 18 years or older who were diagnosed with sepsis and had either lactate ≥ 4 mmol, a documented mean arterial pressure (MAP) < 65 mmHg, or a systolic blood pressure (SBP) < 90 mmHg were included. Charts were reviewed to determine if POCUS was used during the ED evaluation. Primary outcomes were frequency of POCUS use in the cohort, change in POCUS use over the study period, and the types of exams performed. Results: POCUS was used in 21% of encounters meeting inclusion criteria and was positively correlated with ED arrival year (OR = 1.09; CI 1.04, 1.15; p=0.001). The most common POCUS exam was ultrasound-guided central line placement, with the next most common exams being cardiac, followed by inferior vena cava (IVC). Only the frequency of cardiac, IVC, lung and Focused Assessment with Sonography in Trauma (FAST) exams were found to increase significantly over the study period. Conclusions: Total POCUS use increased significantly in this cohort of septic patients over the study period due to more cardiac, IVC, lung and FAST exams being performed.

The role of echocardiography in amniotic fluid embolism: a case series and review of the literature

PURPOSE

Amniotic fluid embolism (AFE) is a rare, but often fatal condition characterized by sudden hemodynamic instability and coagulopathy occurring during labour or in the early postpartum period. As the mechanisms leading to shock and the cardiovascular effects of AFE are incompletely understood, the purpose of this case series is to describe how AFE presents on echocardiography and review limited reports in the literature.

CLINICAL FEATURES

We describe three cases of AFE at the Jewish General Hospital, a tertiary care centre in Montreal, Canada. All cases met the Clark diagnostic criteria, which comprise 1) sudden cardiorespiratory arrest or both hypotension and respiratory compromise, 2) disseminated intravascular coagulation, 3) clinical onset during labour or within 30 min of delivery of the placenta, and 4) absence of fever. Two patients had a cardiac arrest and the third developed significant hypotension and hypoxia. In all patients, point-of-care echocardiography at the time of shock revealed signs of right ventricular failure including a D-shaped septum, acute pulmonary hypertension, and right ventricular systolic dysfunction.

CONCLUSION

This case series and literature review of AFE emphasizes the importance of echocardiography in elucidating the etiology of maternal shock. The presence of right ventricular failure may be considered an important criterion to diagnose AFE.

Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist

Point-of-Care Ultrasound (POCUS) is a valuable bedside diagnostic tool for a variety of expeditious clinical assessments or as guidance for a multitude of acute care procedures. Varying aspects of nearly all organ systems can be evaluated using POCUS and, with the increasing availability of affordable ultrasound systems over the past decade, many now refer to POCUS as the 21^st-century stethoscope. With the current available and growing evidence for the clinical value of POCUS, its utility across the perioperative arena adds enormous benefit to clinical decision-making. Cardiothoracic anesthesiologists routinely have used portable ultrasound systems for nearly as long as the technology has been available, making POCUS applications a natural extension of existing cardiothoracic anesthesia practice. This narrative review presents a broad discussion of the utility of POCUS for the cardiothoracic anesthesiologist in varying perioperative contexts, including the preoperative clinic, the operating room (OR), intensive care unit (ICU), and others. Furthermore, POCUS-related education, competence, and certification are addressed.