1
|
Intraoperative Pulmonary Embolism Diagnosed by Rescue Transesophageal Echocardiography in a Morbidly Obese Patient Undergoing Orthopedic Surgery following Motor Vehicle Crash. Case Rep Anesthesiol 2019; 2019:2429194. [PMID: 31263602 PMCID: PMC6556296 DOI: 10.1155/2019/2429194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/28/2019] [Indexed: 11/17/2022] Open
Abstract
A case of intraoperative pulmonary embolism diagnosed by rescue transesophageal echocardiography in a morbidly obese patient undergoing orthopedic surgery following motor vehicle crash, who developed acute and persistent tachycardia, hypotension, and reduction of end-tidal CO2 during general and regional anesthesia, is described.
Collapse
|
2
|
Gouveia V, Marcelino P, Reuter DA. The role of transesophageal echocardiography in the intraoperative period. Curr Cardiol Rev 2013; 7:184-96. [PMID: 22758616 PMCID: PMC3263482 DOI: 10.2174/157340311798220511] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 02/18/2011] [Accepted: 02/21/2011] [Indexed: 12/17/2022] Open
Abstract
The goal of hemodynamic monitoring and management during major surgery is to guarantee adequate organ perfusion, a major prerequisite for adequate tissue oxygenation and thus, end-organ function. Further, hemodynamic monitoring should serve to prevent, detect, and to effectively guide treatment of potentially life-threatening hemodynamic events, such as severe hypovolemia due to hemorrhage, or cardiac failure. The ideal monitoring device does not exist, but some conditions must be met: it should be easy and operator-independently to use; it should provide adequate, reproducible information in real time. In this review we discuss in particular the role of intraoperative use of transesophageal echocardiography (TOE). Although TOE has gained special relevance in cardiac surgery, its role in major non cardiac surgery is still to be determined. We particularly focus on its ability to provide measurements of cardiac output (CO), and its role to guide fluid therapy. Within the last decade, concepts oriented on optimizing stroke volume and cardiac output mainly by fluid administration and guided by continuous monitoring of cardiac output or so called functional parameters of cardiac preload gained particular attention. Although they are potentially linked to an increased amount of fluid infusion, recent data give evidence that such pre-emptive concepts of hemodynamic optimization result in a decrease in morbidity and mortality. As TOE allows a real time direct visualization of cardiac structures, other potentially important advantages of its use also outside the cardiac surgery operation room can be postulated, namely the ability to evaluate the anatomical and functional integrity of the left and the right heart chambers. Finally, a practical approach to TOE monitoring is presented, based on a local experience.
Collapse
Affiliation(s)
- Veronica Gouveia
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Itzehoe, Germany.
| | | | | |
Collapse
|
3
|
Sekhri V, Mehta N, Rawat N, Lehrman SG, Aronow WS. Management of massive and nonmassive pulmonary embolism. Arch Med Sci 2012; 8:957-69. [PMID: 23319967 PMCID: PMC3542486 DOI: 10.5114/aoms.2012.32402] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 04/15/2012] [Accepted: 04/20/2012] [Indexed: 11/20/2022] Open
Abstract
Massive pulmonary embolism (PE) is characterized by systemic hypotension (defined as a systolic arterial pressure < 90 mm Hg or a drop in systolic arterial pressure of at least 40 mm Hg for at least 15 min which is not caused by new onset arrhythmias) or shock (manifested by evidence of tissue hypoperfusion and hypoxia, including an altered level of consciousness, oliguria, or cool, clammy extremities). Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. A subgroup of patients with nonmassive PE who are hemodynamically stable but with right ventricular (RV) dysfunction or hypokinesis confirmed by echocardiography is classified as submassive PE. Their prognosis is different from that of others with non-massive PE and normal RV function. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and nonmassive pulmonary embolism.
Collapse
Affiliation(s)
- Vishal Sekhri
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Nimeshkumar Mehta
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Naveen Rawat
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Stuart G. Lehrman
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Wilbert S. Aronow
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
- Department of Cardiology, New York Medical College, Valhalla, NY, USA
| |
Collapse
|
4
|
Michelena HI, Abel MD, Suri RM, Freeman WK, Click RL, Sundt TM, Schaff HV, Enriquez-Sarano M. Intraoperative echocardiography in valvular heart disease: an evidence-based appraisal. Mayo Clin Proc 2010; 85:646-55. [PMID: 20592170 PMCID: PMC2894720 DOI: 10.4065/mcp.2009.0629] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Intraoperative (IO) transesophageal echocardiography (TEE) is widely used for assessing the results of valvular heart disease (VHD) surgery. Epiaortic ultrasonography (EAU) has been recommended for prevention of perioperative strokes. To what extent does high-quality evidence justify the widespread use of these imaging modalities? In March 2009, we searched MEDLINE (PubMed and OVID interfaces) and EMBASE for studies published in English using database-specific controlled vocabulary describing the concepts of IOTEE, cardiac surgery, VHD, and EAU. We found no randomized trials or studies with control groups assessing the impact of IOTEE in VHD surgery. Pooled analysis of 8 observational studies including 15,540 patients showed an average incidence of 11% for prebypass surgical changes and 4% for second pump runs, suggesting that patients undergoing VHD surgery may benefit significantly from IOTEE, particularly from postcardiopulmonary bypass IOTEE in aortic repair and mitral repair and replacement, but less so in isolated aortic replacement. Further available indirect evidence was satisfactory in the test accuracy and surgical quality control aspects, with low complication rates for IOTEE. The data supporting EAU included 12,687 patients in 2 prospective randomized studies and 4 nonrandomized, controlled studies, producing inconsistent outcome-related results. Despite low-quality scientific evidence supporting IOTEE in VHD surgery, we conclude that indirect evidence supporting its use is satisfactory and suggests that IOTEE may offer considerable benefit in valvular repairs and mitral replacements. The value of IOTEE in isolated aortic valve replacement remains less clear. Evidence supporting EAU is scientifically more robust but conflicting. These findings have important clinical policy and research implications.
Collapse
Affiliation(s)
- Hector I Michelena
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
| | | | | | | | | | | | | | | |
Collapse
|
5
|
George L. Review of intraoperative TOE. Australas J Ultrasound Med 2009; 12:30-36. [PMID: 28191053 PMCID: PMC5024836 DOI: 10.1002/j.2205-0140.2009.tb00051.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Lenore George
- Department of Anaesthesia Westmead Hospital Sydney New South Wales 2145 Australia
| |
Collapse
|
6
|
Price S, Via G, Sloth E, Guarracino F, Breitkreutz R, Catena E, Talmor D. Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound 2008; 6:49. [PMID: 18837986 PMCID: PMC2586628 DOI: 10.1186/1476-7120-6-49] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Accepted: 10/06/2008] [Indexed: 03/06/2023] Open
Abstract
Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described. Obtaining competence in ICU echocardiography may be achieved in different ways - either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level--obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.
Collapse
Affiliation(s)
- Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
| | - Gabriele Via
- 1st Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, P.zzale Golgi 2, 27100 Pavia, Italy
| | - Erik Sloth
- Department of Anaesthesiology, Skejby Sygehus, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Fabio Guarracino
- Cardiothoracic Anaesthesia and ICU, Azienda Ospedaliera Pisana, via Paradisa 2, 56124 Pisa, Italy
| | - Raoul Breitkreutz
- Department of Anesthesiology, Intensive Care, and Pain therapy, Hospital of the Johann-Wolfgang-Goethe University, Theodor Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Emanuele Catena
- Department of Cardiothoracic Anesthesia, Azienda Ospedaliera Niguarda Ca'Granda, P.za Osp. Maggiore 3, 20100, Milan, Italy
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, USA
| | | |
Collapse
|
7
|
Béïque F, Ali M, Hynes M, MacKenzie S, Denault A, Martineau A, MacAdams C, Sawchuk C, Hirsch K, Lampa M, Murphy P, Honos G, Munt B, Sanfilippo A, Duke P. Canadian guidelines for training in adult perioperative transesophageal echocardiography. Recommendations of the Cardiovascular Section of the Canadian Anesthesiologists' Society and the Canadian Society of Echocardiography. Can J Cardiol 2006; 22:1015-27. [PMID: 17036096 PMCID: PMC2568962 DOI: 10.1016/s0828-282x(06)70317-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To establish Canadian guidelines for training in adult perioperative transesophageal echocardiography (TEE). METHODS Guidelines were established by the Canadian Perioperative Echocardiography Group with the support of the cardiovascular section of the Canadian Anesthesiologists' Society in conjunction with the Canadian Society of Echocardiography. Guidelines for training in echocardiography by the American Society of Echocardiography, the American College of Cardiology and the Society of Cardiovascular Anesthesiologists were reviewed, modified and expanded to produce the 2003 Quebec expert consensus for training in perioperative echocardiography. The Quebec expert consensus and the 2005 guidelines for the provision of echocardiography in Canada formed the basis of the Canadian training guidelines in adult perioperative TEE. RESULTS Basic, advanced and director levels of expertise were identified. The total number of echocardiographic examinations to achieve each level of expertise remains unchanged from the 2002 American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists guidelines. The increased proportion of examinations personally performed at basic and advanced levels, as well as the level of autonomy at the basic level suggested by the Quebec expert consensus are retained. These examinations may be performed in a perioperative setting and are not limited to intraoperative TEE. Training 'on-the-job', the role of the perioperative TEE examination, the requirements for maintenance of competence and the duration of training are also discussed for each level of training. The components of a TEE report and comprehensive TEE examination are also outlined. CONCLUSION The Canadian guidelines for training in adult perioperative TEE reflect the unique Canadian practice profile in perioperative TEE and address the training requirements to obtain expertise in this field.
Collapse
Affiliation(s)
- François Béïque
- Department of Anesthesia, Sir Mortimer B Davis Jewish General Hospital, McGill University, Montreal, Quebec
- Correspondence: Dr François Béïque, Sir Mortimer B Davis Jewish General Hospital, 3755 chemin de la Côte Ste-Catherine, Montreal, Quebec H3T 1E2. Telephone 514-340-8222 ext 5701, fax 514-340-8108, e-mail
| | - Mohamed Ali
- Department of Anesthesia and Surgery, Kingston General Hospital, Queen’s University, Kingston
| | - Mark Hynes
- Department of Anesthesia and Critical Care Medicine, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario
| | - Scott MacKenzie
- Departments of Anesthesia and Medicine, St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, University of Montreal, Montreal
- Department of Medicine, Critical Care Division, Montreal Heart Institute, University of Montreal, Montreal
| | - André Martineau
- Department of Anesthesia, Quebec Heart Institute/Laval Hospital, Laval University, Quebec City, Quebec
| | - Charles MacAdams
- Department of Anesthesia, Foothills Medical Centre, University of Calgary, Calgary, Alberta
| | - Corey Sawchuk
- Department of Anesthesia, McMaster University, Hamilton, Ontario
| | - Kristine Hirsch
- Department of Anesthesia, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia
| | - Martin Lampa
- Department of Anesthesia, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia
| | - Patricia Murphy
- Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario
| | - Georges Honos
- Department of Medicine, Division of Cardiology, Sir Mortimer B Davis Jewish General Hospital, McGill University, Montreal, Quebec
| | - Bradley Munt
- Department of Medicine, Division of Cardiology, St Paul’s Hospital and Providence Health Care, University of British Columbia, Vancouver, British Columbia
| | - Anthony Sanfilippo
- Department of Medicine, Kingston General Hospital Queen’s University, Kingston, Ontario
| | - Peter Duke
- Departments of Anesthesia and Surgery, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba
| |
Collapse
|
8
|
Subramaniam B, Soriano SG, Michael Scott R, Kussman BD. Anesthetic management of pial synangiosis and intracranial hemorrhage with a Fontan circulation. Paediatr Anaesth 2006; 16:72-6. [PMID: 16409534 DOI: 10.1111/j.1460-9592.2005.01598.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report the case of a 11-year-old girl with Moyamoya syndrome, who had undergone staged-repair of tricuspid atresia to a Fontan circulation, scheduled to undergo bilateral pial synangiosis. Surgery for the first hemisphere was complicated by intracranial hemorrhage requiring an emergency craniotomy. The case highlights the importance of understanding Fontan physiology and its interrelationship with the cerebral circulation in the setting of cerebrovascular insufficiency and raised intracranial pressure.
Collapse
Affiliation(s)
- Balachundhar Subramaniam
- Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Boston, MA 02115, USA
| | | | | | | |
Collapse
|
9
|
Rosenberger P, Shernan SK, Body SC, Eltzschig HK. Utility of intraoperative transesophageal echocardiography for diagnosis of pulmonary embolism. Anesth Analg 2004; 99:12-16. [PMID: 15281493 DOI: 10.1213/01.ane.0000117284.25696.64] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Pulmonary embolism (PE) is associated with significant perioperative morbidity and mortality. Transesophageal echocardiography (TEE) may permit direct visualization of PE or secondary signs of pulmonary artery (PA) obstruction. However, its utility in diagnosing PE in the intraoperative setting has yet to be defined. Therefore, we performed intraoperative TEE examinations in 46 patients immediately before pulmonary embolectomy. TEE examinations were reviewed for signs of thromboemboli within the right, left, and main PA, and secondary signs of acute PA obstruction (right ventricular dysfunction, moderate-to-severe tricuspid regurgitation, leftward bowing of the interatrial septum). The definitive location of thromboemboli was determined from the surgical record. Echocardiographic evidence for the presence of PE was correctly demonstrated in 46% of all patients (n = 21 of 46). However, the sensitivity for direct visualization of thromboemboli at any specific location was only 26%. TEE was least sensitive for thromboemboli in the left PA (17%). TEE evidence of right ventricular dysfunction was observed in 96%, tricuspid regurgitation in 50%, and leftward interatrial septal bowing in 98% of examinations. Therefore, the use of intraoperative TEE to diagnose acute PE via direct visualization is limited. Indirect TEE evidence of PA obstruction may be helpful in supporting a diagnosis of PE.
Collapse
Affiliation(s)
- Peter Rosenberger
- * Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts; and † Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany
| | | | | | | |
Collapse
|
10
|
Affiliation(s)
- Daniel M Thys
- Department of Anesthesiology, St. Luke's-Roosevelt Hospital Center, New York, New York
| |
Collapse
|