Variations of transesophageal echocardiography practices in India: A survey by Indian College of Cardiac Anaesthesia

The Use of Pulmonary Artery Catheters and Echocardiography in the Cardiac Surgery Setting: A Nationwide Italian Survey

OBJECTIVE

Wide variations exist in the use of pulmonary artery catheters (PACs) and echocardiography in the field of cardiac surgery.

DESIGN

A national survey promoted by the Italian Association of Cardio-Thoracic Anesthesiologists and Intensive Care was conducted.

SETTING

The study occurred in Italian cardiac surgery centers (n = 71).

PARTICIPANTS

Anesthesiologists-intensivists were enrolled.

INTERVENTIONS

Anonymous questionnaires were used to investigate the use of PACs and echocardiography in the operating room (OR) and intensive care unit (ICU).

MEASUREMENTS AND MAIN RESULTS

A total of 257 respondents (32.2% response rate) from 59 centers (83.1% response rate) participated. Use of PACs seems less common in ORs (median insertion in 20% [5-70] of patients), with slightly higher use in ICUs; in about half of cases, it was the continuous cardiac output monitoring system of choice. Almost two-thirds of respondents recently inserted at least one PAC within a few hours of ICU admission, despite its need being largely preoperatively predictable. Protocols regulating PAC insertion were reported by 25.3% and 28% of respondents (OR and ICU, respectively). Transesophageal echocardiography (TEE) was performed intraoperatively in >75% of patients by 86.4% of respondents; only 23.7% stated that intraoperative TEE relied on anesthesiologists. Tissue Doppler and/or 3D imaging were widely available (87.4% and 82%, respectively), but only 37.8% and 24.3% of respondents self-declared skills in these modalities, respectively; 77.1% of respondents had no echocardiography certification, nor were pursuing certification (various reasons); 40.9% had not attended recent echocardiography courses. Lower PAC use was associated with university hospitals (OR: p = 0.014, ICU: p = 0.032) and with lower interventions/year (OR: p = 0.023). Higher independence in performing TEE was reported in university hospitals (OR: p < 0.001; ICU: p = 0.006), centers with higher interventions/year (OR: p = 0.019), and by respondents with less experience in cardiology (ICU: p = 0.046).

CONCLUSION

Variability in the use of PACs and echocardiography was found. Protocols regulating the use of PACs seem infrequent. University centers use PACs less and have greater skills in TEE. Training and certifications in echocardiography should be encouraged.

Heterogeneity Among Countries in the Subspecialty of Cardiovascular Anesthesia in Latin America: Survey Results

OBJECTIVES

To evaluate demographics, workload, training, facilities, and equipment in cardiovascular anesthesia (CVA) in Latin America (LA).

DESIGN

A descriptive cross-sectional study with data collected through a survey.

SETTING

A multicenter, international web-based questionnaire that included 37 multiple-choice questions.

PARTICIPANTS

Physicians and specialists in anesthesiology who regularly participated in cardiovascular surgeries and were members of the scientific societies of the Latin American Confederation of Anesthesiology.

INTERVENTIONS

None MEASUREMENTS AND MAIN RESULTS: A total of 484 completed questionnaires were collected. A total of 97.8% of the respondents had a university degree in anesthesiology. Most did not receive formal training in CVA, and only 41.5% received formal training. Moreover, most of them were trained in their own country, and a smaller percentage were trained abroad. Half of the respondents reported receiving <12 months of training. A third part of the respondents had received training in transesophageal echocardiography. Only 5.8% of the respondents worked exclusively in CVA, and a high percentage dedicated <60% of their weekly work hours to this subspecialty. A total of 80.6% of the centers had <3 cardiac surgery operating rooms. Only one-third of the centers performed heart/lung transplantation, venoarterial extracorporeal membrane oxygenation, venovenous extracorporeal membrane oxygenation, and ventricular assist device implantation.

CONCLUSIONS

A significant lack of training programs in anesthesiology practice and complex procedures in medical centers in LA are evident. Thus, basic accredited programs should be developed in medical centers in LA.

Normative Transesophageal Echocardiographic Values of Cardiac Structures in the Indian Population-Indian Normative TEE Measurements (INTEEM) Study

OBJECTIVES

Information on normative reference values for cardiac structures is critical for the accurate application of echocardiography for guiding clinical decision-making. Many studies using transthoracic echocardiography (TTE) have shown that Indians have smaller diameters of various cardiac structures. There are no normative studies for transesophageal echocardiography (TEE). The authors observed dimensions of various cardiac structures in healthy Indian patients under general anesthesia using TEE and compared them with existing guidelines from non-Indian data.

DESIGN

The Indian Normative TEE Measurements study was a multicenter, prospective observational study conducted in India.

SETTING

Operating rooms for noncardiac surgeries in tertiary care-level hospitals.

PARTICIPANTS

Adult patients undergoing noncardiac surgery who were free from any cardiac, respiratory, and renal diseases and had no contraindications for TEE.

INTERVENTIONS

After inducing general anesthesia and achieving stable hemodynamic conditions, a comprehensive TEE examination was performed and various measurements were made.

MEASUREMENTS AND MAIN RESULTS

For each of the 83 patients undergoing noncardiac surgery, 39 various measurements for left ventricle, right ventricle, both atria, and all valves were made. This included diameters and functional parameters. They were analyzed in a vendor-neutral software off-line. The absolute values of many of the measurements were higher in men, but when indexed to body surface area (BSA) they were similar in both sexes. The values were lower than most of the Western data but matched previous Indian studies using TTE.

CONCLUSIONS

The authors present normative values of various echocardiographic parameters using TEE. Because of its variations, it is recommended to use India-specific data to make decisions in Indian patients. It may be prudent to use BSA-indexed values during decision-making.

A career in cardiac anaesthesia in India: The heart of the matter

Cardiac anaesthesia is a demanding, but fulfilling speciality which challenges the skills, knowledge, professional and personal competence of cardiac anaesthesiologists on a daily basis. This article outlines the brief history of the subspecialty of cardiac anaesthesia in India, its growth and progress over the decades, reasons for choosing it as a career option, variations in practice standards and how the speciality has been affected by the coronavirus 2019 pan?demic.

Does the endotracheal tube cuff pressure increases with transesophageal probe insertion?

Context:

The cuff pressure (CP) of the endotracheal tube (ETT) exceeding 30 cm of H₂O results in reduced perfusion of lateral mucosa of trachea leading to complications. As the posterior tracheal wall is in contact with the esophagus, there is a possibility that the insertion of transesophageal echo (TEE) probe may compress the tracheal wall and increase CP.

Aims:

This study was aimed to assess the impact of TEE probe insertion on CP in adults undergoing cardiac surgery.

Settings and Design:

Prospective observational study of 65 patients at tertiary care level hospital.

Subjects and Methods:

After balanced general anesthesia, patients were intubated with high volume low-pressure ET.TEE probe was then inserted with gentle jaw thrust. CP was measured by standard invasive pressure monitoring device at four points: T1 at baseline before TEE probe insertion; T2 maximum CP noted at TEE probe insertion; T3 at 5 min post TEE probe insertion; and T4 at post-TEE exam.

Statistical Analysis Used:

CP was compared between pairs of time points (T1 vs. T2; T1 vs. T3; and T1 vs. T4) using Mann-Whitney U test. Factors predicting CP >30 cm of H₂O at T4 were assessed by backward stepwise regression.

Results:

CP (mean ± S.D.) at T1, T2, T3, and T4 was 22 ± 3, 38 ± 10, 30 ± 6, and 30 ± 7, respectively. CP increased significantly from T1 to T2 (P < 0.001), T1 to T3 (P < 0.001), and T1 to T4 (P < 0.001). There were 26 patients (40%) with CP >30 cm of H₂O at end of TEE exam (T4). On multivariate analysis baseline, CP (T1) >20 cm of H₂O was significantly associated with CP >30 cm of H₂O at end of TEE exam with Odd's Ratio (OR) of 8.5 (1.76–41.06, P = 0.008).

Conclusions:

To conclude, the CP increases significantly with TEE probe insertion in 40% of patients exceeding a safe limit of 30 cm of H₂O. The monitoring and optimization of CP is advisable.

A survey of practices during cardiopulmonary bypass in India: An Indian association of cardiovascular and thoracic anesthesiologist endeavor

Context:

Cardiac anesthesiologists play a key role during the conduct of cardiopulmonary bypass (CPB). There are variations in the practice of CPB among extracorporeal technologists in India.

Aims:

The aim of this survey is to gather information on variations during the conduct of CPB in India.

Settings and Design:

This was an online conducted survey by Indian College of Cardiac Anaesthesia, which is the research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists.

Subjects and Methods:

Senior consultants heading cardiac anesthesia departments in both teaching and nonteaching centers (performing at least 15 cases a month) were contacted using an online questionnaire fielded using SurveyMonkey™ software. There were 33 questions focusing on institute information, perfusion practices, blood conservation on CPB; monitoring and anesthesia practices.

Results:

The response rate was 74.2% (187/252). Fifty-one (26%) centers were teaching centers; 18% centers performed more than 1000 cases annually. Crystalloid solution was the most common priming solution used. Twenty-three percent centers used corticosteroids routinely; methylprednisone was the most commonly used agent. The cardioplegia solution used by most responders was the one available commercially containing high potassium St. Thomas solution (55%), followed by Del Nido cardioplegia (33%). Majority of the responders used nasopharyngeal site to monitor intraoperative patient temperature. Antifibrinolytics were commonly used only in patients who were at high risk for bleeding by 51% of responders, while yet, another 39% used them routinely, and 11% never did. About 59% of the centers insist on only fresh blood (<7 days old) when blood transfusion was indicated. The facility to use vaporizer on CPB was available in 62% of the centers. All the teaching centers or high volume centers in India had access to transesophageal echocardiography probe and echo machine, with 51% using them routinely and 38% using them at least sometimes.

Conclusions:

There is a wide heterogeneity in CPB management protocols among various Indian cardiac surgery centers. The survey suggests that adherence to evidence-based and internationally accepted practices appears to be more prevalent in centers that have ongoing teaching programs and/or have high volumes, strengthening the need to devise guidelines by appropriate body to help bring in uniformity in CPB management to ensure patient safety and high quality of clinical care for best outcomes.

Fifteen Years of Transesophageal Echocardiography in Cardiac Anesthesia in Russia

Transesophageal echocardiography was first introduced in Russia as a component of anesthesiology monitoring in 2003 following its successful implementation in the practice of cardiac anesthesia in the United States and Western Europe. This novel opportunity for perioperative hemodynamic evaluation was enthusiastically adopted at several cardiac surgical clinics despite the presence of critical barriers. The most important of these were the lack of certification programs for anesthesiologists, limited equipment, and a lack of understanding of the responsibility of the anesthesiologist as the coordinator of perioperative therapeutic decisions. Although intraoperative transesophageal echocardiography as a part of the anesthesiology protocol has been introduced in less than 10% of Russian cardiac surgery clinics, a group of interested anesthesiologists has formed over the last 15 years. Both the technical conditions and professional mentality of anesthesiologists need to be changed substantially for successful further development of intraoperative echocardiography. This review aims to highlight the milestones, successes, and challenges in the implementation of intraoperative echocardiography in the practice of cardiac anesthesiology in Russia, which may be interesting to a wide range of cardiac anesthesiologists.

History of Cardiac Anesthesia in India

Before the 19th century, the heart was considered as a "no-go" area, although minor and superficial procedures were performed in the early 1800s. It was only in the later part of the century that surgical repair of the wounds of the cardiac chambers was attempted. Cardiac surgery came to India in the mid-20th century and the operations performed were minor and extracardiac. Initially, the surgeries were performed at a select few centers located at Mumbai, Vellore, Delhi, Chennai, and Kolkata. The anesthesiologists of an earlier era in India worked with limited facilities, and with their interest and devotion contributed immensely to the growth of the specialty of cardiac anesthesia. The progress was somewhat modest until the 1980s, when it started increasing rapidly and India caught up with the Western world by the turn of century. The progress was seen not only in the clinical field, but also in technology, teaching, and academic fields. This article presents an account of the progress in the field of cardiac anesthesia in India, and highlights the contribution of some of the dedicated anesthesiologists because of whom the specialty has reached the present stature.