Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care

Usefulness of point of care ultrasound in older adults: a multicentre study across different geriatric care settings in Spain and the United Kingdom

BACKGROUND

Point of care ultrasound (POCUS) is an imaging technique performed bedside. To date, few published studies have reported the usefulness of multiorgan POCUS in Geriatrics. The objective of this study was to describe the utility of multiorgan POCUS in the care of older adults admitted to geriatric care settings.

METHODOLOGY

Observational retrospective study of patients admitted to geriatric settings in Spain and UK. Multiorgan POCUS was performed when there was a specific clinical suspicion or unexplained torpid clinical course despite physical examination and complementary tests. A geriatrician with a certificate degree in comprehensive ultrasound and long-standing experience in POCUS carried out POCUS. All patients underwent multiorgan POCUS in a cephalo-caudal manner.

RESULTS

Out of 368 patients admitted to geriatric units, 29% met the inclusion criteria. Average age was 85.9 years (SD ± 6.1). POCUS identified 235 clinically significant findings (2.2 per patient). Findings were classified as 37.9% confirmed diagnosis, 16.6% ruled out diagnosis, 14.9% unsuspected relevant diagnoses and 30.6% clinical follow-ups. POCUS findings led to changes in pharmacological and non-pharmacological treatment in 66.3 and 69.2% respectively, resulted in completion or avoidance of invasive procedures in 17.8 and 15.9%, respectively, facilitating early referrals to other specialities in 14.9% and avoiding transfers in 25.2% of patients.

CONCLUSION

Multiorgan POCUS is a tool that aids in the assessment and treatment of patients receiving care in geriatrics units. These results show the usefulness of POCUS in the management of older adults and suggest its inclusion in any curriculum of Geriatric Medicine speciality training.

Ultrasound in anesthesiology in the Nordic countries-Protocol of an international survey on availability, frequency of use, operator training, and certification

BACKGROUND

Over the past decade, ultrasound utilization has increased within anesthesia and intensive care medicine, enhancing patient safety and diagnostic accuracy. However, the frequency of ultrasound usage and operator training in the Nordic countries remain unclear. This project aims to perform a survey on ultrasound availability, daily clinical use, and how ultrasound skills are trained and assessed, among anesthesiologists.

METHODS

This online cross-sectional survey will include anesthesiologists from the Nordic countries. The survey will adhere to the CROSS checklist. Survey items will be developed based on a formative model with a conceptual model, consisting of three main parts, including demographics, ultrasound machines and use, and skills development and assessment. The clinical relevance of items will be secured by including anesthesiologists of various levels of experience in the development of the survey. Furthermore, experienced researchers in medical education will participate in the development, contributing with relevant medical educational perspectives. Data will be summarized using a non-parametric descriptive approach. A chi-squared test will examine relevant relationships between certain answers.

RESULTS

Results will be published in a peer-reviewed journal and presented at relevant scientific conferences and meetings.

CONCLUSION

This study may find a high availability of ultrasound machines and frequent use in the clinical departments. Despite this expected daily use of ultrasound, missing standardized structured skills acquisition and assessment could be uncovered. The results of this study may contribute to mapping various aspects of clinical ultrasound and skills development for further use in research.

Regional anesthesia and POCUS in the intensive care unit

This chapter focuses on resident recruitment and recent US National Resident Matching Program changes and the impact in the evaluation and ranking of applicants within the specialty of anesthesiology. Recruitment challenges are examined as well as program strategies and potential future directions. Also discussed are DEI initiatives within the recruitment process.

The Influence of Food Intake and Preload Augmentation on Cardiac Functional Parameters: A Study Using Both Cardiac Magnetic Resonance and Echocardiography

(1) Background: To investigate how food intake and preload augmentation affect the cardiac output (CO) and volumes of the left ventricle (LV) and right ventricle (RV) assessed using cardiac magnetic resonance (CMR) and trans-thoracic echocardiography (TTE). (2) Methods: Eighty-two subjects with (n = 40) and without (n = 42) cardiac disease were assessed using both CMR and TTE immediately before and after a fast infusion of 2 L isotonic saline. Half of the population had a meal during saline infusion (food/fluid), and the other half were kept fasting (fasting/fluid). We analyzed end-diastolic (EDV) and end-systolic (ESV) volumes and feature tracking (FT) using CMR, LV global longitudinal strain (GLS), and RV longitudinal strain (LS) using TTE. (3) Results: CO assessed using CMR increased significantly in both groups, and the increase was significantly higher in the food/fluid group: LV-CO (ΔLV-CO: +2.6 ± 1.3 vs. +0.7 ± 1.0 p < 0.001), followed by increased heart rate (HR) (ΔHR: +12 ± 8 vs. +1 ± 6 p < 0.001). LV and RV achieved increased stroke volume (SV) through different mechanisms. For the LV, through increased contractility, increased LV-EDV, decreased LV-ESV, increased LV-FT, and GLS were observed. For the RV, increased volumes, increased RV-EDV, increased RV-ESV, and at least for the fasting/fluid group, unchanged RV-FT and RV-LS were reported. (4) Conclusions: Preload augmentation and food intake have a significant impact on hemodynamic and cardiac functional parameters. This advocates for standardized recommendations regarding oral intake of fluid and food before cardiac assessment, for example, TTE, CMR, and right heart catheterization. We also demonstrate different approaches for the LV and RV to increase SV: for the LV by increased contractility, and for the RV by volume expansion.

Perioperative Point of Care Ultrasound for Hemodynamic Assessment: A Narrative Review

While transesophageal echocardiography (TEE) has traditionally been used in perioperative care, there is growing evidence supporting point of care ultrasound (POCUS) for the anesthesiologist in guiding patient care. It is a quick way to non-invasively evaluate hemodynamically unstable patients and ascertain their state of shock, determine volume status, and guide resuscitation in cardiac arrest. In addition, through use of POCUS, the anesthesiologist is able to identify signs of chronic heart disease to provide a more tailored and safer approach to perioperative care.

Severe hypertrophic cardiomyopathy with left ventricular outflow tract obstruction identified with preprocedural point-of-care ultrasound before emergent tracheal repair

A woman in her 60s was brought to the operating room directly from the trauma bay for emergent intervention to repair a tracheal rupture sustained during a reported fall from standing height. She was intubated and sedated prior to arrival by paramedics for respiratory distress. Her family reported that the patient had dizziness after standing followed by the patient fainting and striking her neck. During a preprocedural point-of-care cardiac ultrasound examination, we discovered severe left ventricular hypertrophy with a significantly increased ejection fraction and decreased left ventricular cavity size. This prompted emergent cardiology consultation, which confirmed the presence of severe hypertrophic cardiomyopathy with left ventricular outflow tract obstruction. After a brief delay to optimise her heart rate and volume status, the patient successfully underwent an open reduction and internal fixation of the laryngeal cartilage and was discharged in stable condition with plans to undergo a septal myotomy.

Focused Cardiac Ultrasound to Guide the Diagnosis of Heart Failure in Pregnant Women in India

BACKGROUND

Cardiac complications are a leading cause of maternal death. Cardiac imaging with echocardiography is important for prompt diagnosis, but it is not available in many low-resource settings. The aim of this study was to determine whether focused cardiac ultrasound performed by trained obstetricians and interpreted remotely by experts can identify cardiac abnormalities in pregnant women in low-resource settings.

METHODS

A cross-sectional study was conducted among 301 pregnant and postpartum women recruited from 10 hospitals across three states in India. Twenty-two obstetricians were trained in image acquisition using a portable cardiac ultrasound device following a simplified protocol adapted from focus-assessed transthoracic echocardiography protocol. It included parasternal long-axis, parasternal short-axis, and apical four-chamber views on two-dimensional and color Doppler. Independent image interpretation was performed remotely by two experts, in the United Kingdom and India, using a standard semiquantitative assessment protocol. Interrater agreement between the experts was examined using Cohen's κ. Diagnostic accuracy of the method was examined in a subsample for whom both focused and conventional scans were available.

RESULTS

Cardiac abnormalities identified using the focused method included valvular abnormalities (27%), rheumatic heart disease (6.6%), derangements in left ventricular size (4.7%) and function (22%), atrial dilatation (19.5%), and pericardial effusion (30%). There was substantial agreement on the cardiac parameters between the two experts, ranging from 93.6% (κ = 0.84) for left ventricular ejection fraction to 100% (κ = 1) for valvular disease. Image quality was graded as good in 79% of parasternal long-axis, 77% of parasternal short-axis and 64% of apical four-chamber views. The chance-corrected κ coefficients indicated fair to moderate agreement (κ = 0.28-0.51) for the image quality parameters. There was good agreement on diagnosis between the focused method and standard echocardiography (78% agreement), compared in 36 participants.

CONCLUSIONS

The focused method accurately identified cardiac abnormalities in pregnant women and could be used for screening cardiac problems in obstetric settings.

Bedside Chest Ultrasound in Postoperative Pediatric Cardiac Surgery Patients: Comparison With Bedside Chest Radiography

OBJECTIVE

The primary objective was to study the degree of agreement between the chest ultrasound (CUS) studies and chest x-ray (CXR) studies in postoperative pediatric cardiac surgical patients regarding the diagnosis of thoracic abnormalities, and also to compare the diagnostic performance of CUS in reference to CXR for the detection of thoracic abnormalities. The secondary objective was to compare the necessity for interventions done on the basis of CUS and CXR findings in the postoperative setting.

DESIGN

A prospective observational study.

SETTING

At a postoperative pediatric cardiac surgical intensive care unit in a tertiary-care center.

PARTICIPANTS

One hundred sixty patients between the age of 2 months to 18 years undergoing elective cardiac surgery for various congenital heart diseases.

INTERVENTIONS

After obtaining permission from the institutional ethics committee, 160 pediatric cardiac surgical patients were studied prospectively in the postoperative period. On the day of surgery (postoperative day [POD] 0), bedside CXR was done in the immediate postoperative period. After bedside CXR, CUS examination was performed and then interpreted by the principal investigator. The CXR was interpreted by the surgical team. Provisional diagnosis was made by the principal investigator and surgical team. Any intervention required was decided based on CXR or CUS findings or both. The procedure was repeated in the morning of POD 1.

MEASUREMENTS AND MAIN RESULTS

The degree of agreement between CUS studies and CXR studies in detecting abnormalities was evaluated by Cohen's kappa (k) statistics. The diagnostic performance of CUS was compared with that of CXR using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy. Overall, kappa analysis (k) showed substantial agreement between the findings of the CUS and CXR studies (k = 0.749). The diagnostic performance of CUS, as compared with CXR, was found to have a sensitivity of 96.9%, specificity of 84.75%, PPV of 73.4%, NPV of 98.43%, and diagnostic accuracy of 88.44%. In 94 abnormal findings, the interventions were done based on CUS or CXR findings or both. Overall, there was a substantial agreement (k = 0.787) between CUS and CXR regarding the necessity for interventions.

CONCLUSIONS

The degree of agreement between CUS and CXR studies was substantial for atelectasis, interstitial edema, and diaphragmatic weakness. The degree of agreement between CUS and CXR studies was almost perfect for pneumothorax and fair for pleural effusion. More CUS studies detected intrathoracic pathologies than CXR studies. The CUS also detected abnormalities earlier than CXR and was found to be useful for the early institution of intervention therapy in patients with interstitial edema and atelectasis. It would be reasonable to conclude that CUS may be considered in some instances as an alternative to CXR.

Use of Point-of-Care Ultrasound and Focus-Assessed Transthoracic Echocardiography to Diagnose Acute Right Heart Failure Due to Fat Emboli in a Parturient

Fat embolism syndrome (FES), causing right heart dysfunction, is a rare disease that is often difficult to diagnose with imaging modalities such as computed tomography (CT). FES is the clinical presentation that follows the entry of fat globules into the systemic circulation, which typically results in respiratory failure, scattered petechiae, cardiovascular collapse, and neurological sequelae. It is mostly observed in the cases of orthopedic trauma but may occur in any circumstance where fat can enter the circulatory system. In this case report, the authors describe an atypical presentation of FES in a 24-week parturient. The use of bedside point-of-care ultrasonography (POCUS) and the focus-assessed transthoracic echocardiography (FATE) protocol aided in the prompt diagnosis of right heart failure and helped to confirm the diagnosis of FES with more advanced imaging technology.

Haemodynamic monitoring in acute heart failure - what you need to know

Acute heart failure (AHF) is a sudden, life-threatening condition, defined as a gradual or rapid onset of symptoms and/or signs of HF. AHF requires urgent medical attention, being the most frequent cause of unplanned hospital admission in patients above 65 years of age. AHF is associated with a 4–12% in-hospital mortality rate and a 21–35% 1-year mortality rate post-discharge. Considering the serious prognosis in AHF patients, it is very important to understand the mechanisms and haemodynamic status in an individual AHF patient, thus preventing end-organ failure and death. Haemodynamic monitoring is a serial assessment of cardiovascular function, intended to detect physiologic abnormalities at the earliest stages, determine which interventions could be most effective, and provide the basis for initiating the most appropriate therapy and evaluate its effects. Over the past decades, haemodynamic monitoring techniques have evolved greatly. Nowadays, they range from very invasive to non-invasive, from intermittent to continuous, and in terms of the provided parameters. Invasive techniques contain pulmonary artery catheterization and transpulmonary thermodilution. Minimally invasive techniques include oesophageal Doppler and noncalibrated pulse wave analysis. Non-invasive techniques contain echocardiography, bioimpedance, and bioreactance techniques as well as non-invasive pulse contour methods. Each of these techniques has specific indications and limitations. In this article, we aimed to provide a pathophysiological explanation of the physical terms and parameters used for haemodynamic monitoring in AHF and to summarize the working principles, advantages, and disadvantages of the currently used methods of haemodynamic monitoring.

Paradoxical venous air embolism detected with point-of-care ultrasound: a case report

Venous air embolism (VAE) is an uncommon event consistent in the entrainment of air from any communication between the environment and the venous vasculature that could occur during central venous catheter (CVC) manipulation, and might trigger circulatory shock within minutes depending on the amount of air embolized. We present a case of a critical care patient who presented sudden clinical hemodynamic deterioration after the removal of central venous catheter. Hemodynamic evaluation with point-of-care ultrasound (POCUS) showed bubbles in both right and left heart cavities wherewith air embolism facilitated by heart septal defect was suspected. Therefore, the patient was reintubated, supported with vasopressors and a new CVC was inserted to proceed with air aspiration. Shortly after, the patient’s hemodynamic status improved in terms of vital signs stabilization. 6 h after the event with optimal perfusion markers and diminished sedation, the patient showed left hemiparesis therefore a cerebral magnetic resonance (MRI) was also performed showing hyperintensity in the right precentral gyrus, so ischemic stroke without hemorrhagic transformation diagnosis was made, because of paradoxical embolism. This case report demonstrates the value of POCUS application as a diagnostic tool in the hemodynamically unstable patient.

Thrombotic pulmonary embolism of inferior vena cava during caesarean section: A case report and review of the literature

BACKGROUND

Thrombotic pulmonary embolism (TPE) is one of the most critical diseases in obstetrics but is rarely reported in caesarean section (CS) because TPE patients in CS have a high risk of death and are difficult to diagnose. This case report of TPE during CS was recorded by transthoracic echocardiography (TTE) and can provide a reference for the differential diagnosis of critical illnesses in CS.

CASE SUMMARY

A 37-year-old pregnant woman with rheumatic heart disease (RHD), gravida 5 and para 1 (G5P1), presented for emergency CS at 33 wk and 3 d of gestation under general anesthesia because of acute heart failure, pulmonary hypertension and arrhythmia. After placental removal during CS, TTE revealed a nascent thrombus in the inferior vena cava (IVC) that elongated, detached and fragmented leading to acute thromboembolic events and acute TPE. This report presents the whole process and details of TPE during CS and successful rescue without any sequelae in the patient. This case gives us new ideas for the diagnosis of death or cardiovascular accidents during CS in pregnant women with heart disease and the detailed presentation of the rapid development of TPE may also elucidate new ideas for treatment. This case also highlighted the importance of prophylactic anticoagulation in the management of heart disease during pregnancy.

CONCLUSION

Pregnancy with heart failure could trigger inferior vena cava (IVC)-origin TPE during CS. Detection and timely treatment can avoid serious consequences.

Quantitative Echocardiography Improves Resident Assessment of Left Ventricular Systolic Function

BACKGROUND

The use of echocardiography to assess left ventricular ejection fraction (LVEF) is an important component of anesthesiology resident education; however, there is no consensus on the most effective method for teaching this skill set. This study investigates the impact and feasibility of teaching a quantitative LVEF assessment method to anesthesiology residents, compared with teaching visual estimation techniques.

METHODS

We included all anesthesiology residents rotating through cardiac anesthesia at our institution from August 2020 through March 2021. Participants completed a pretest to assess baseline ability to accurately estimate LVEF. All tests consisted of transthoracic echocardiography images with standard views from 10 patients. Participants were assigned to either a control group that received teaching on visual estimation of LVEF or an intervention group that was taught quantitative LVEF assessment with the Simpson biplane method of discs. After 4 weeks, all participants were administered a postteaching exam. A retention exam was administered an additional 4 weeks later. LVEF accuracy was measured as the absolute difference between their LVEF estimation and the reference value.

RESULTS

Control and intervention groups performed similarly on the preteaching exam of LVEF estimation accuracy. Intervention-group residents demonstrated significantly improved accuracy in LVEF assessment on the postteaching exam (3.6% improvement in accuracy, confidence interval [CI], 1.23-5.97; P = .03) compared with the control group (0.60% improvement inaccuracy, CI, -1.77-2.97; P = .62). The observed improvement was not maintained through the retention exam.Conclusions: Addition of quantitative LVEF assessment to traditional teaching of visual LVEF estimation methods significantly improved the diagnostic accuracy of anesthesiology residents' left ventricular systolic function assessment.

Short-term impact of COVID-19 infection on right ventricular functions: single center observational study

Background

COVID-19 pandemic is associated with high morbidity and mortality. Cardiovascular insult is a leading cause of in-hospital mortality in COVID-19 patients, especially right ventricular (RV) dysfunction and massive pulmonary embolism. This study aims to assess short-term impact of COVID 19 infection on (RV) functions among hospitalized patients with moderate or severe illness using bed side trans-thoracic echocardiogram. This study was conducted in 3 isolation hospitals in Cairo, spanning over 3 months during the expected pandemic peak in Egypt in 2020. The study recruited 100 consecutive patients with moderate or severe COVID-19 infection. Four patients refused to participate in the study. Patients with pre-existing structural heart diseases were excluded. All patients underwent full history taking and clinical examination. Bed side echocardiography was done emphasizing on (RV), and (RA) dimensions, (LV) functions and pulmonary artery systolic pressure (PSAS). Cardiac biomarkers were withdrawn and CT angiography was ordered when clinically warranted.

Results

The mean age of the studied cohort was 59.5 ± 8.6 years with males comprising 71.9% of the studied group. (RV) and (RA) dilatation was noted in 8 cases (8.3%). (LV) dysfunction was noted in 11 cases (11.4%). (PASP) showed a statistically significant negative correlation with (LV) function. However, (PSAP) was positively correlated to (RA) and (RV) dimensions, tricuspid regurgitation (TR) jet severity, previous COVID infection and elevated cardiac biomarkers. Mortality was noted in 3 cases (3.1%), all had LV dysfunction with elevated troponin level. Six patients (6.2%) had combined (LV) and (RV) dysfunction.

Conclusions

COVID-19 illness had a negative impact on (RV) and (LV) functions, that could be assessed accurately by trans-thoracic 2 D echocardiogram. The degree of ventricular dysfunction correlated with the rise in cardiac biomarkers as well as the degree of (PASP).

[Focus ultrasound for cardiology practice. Russian consensus document]

This document is a consensus document of Russian Specialists in Heart Failure, Russian Society of Cardiology, Russian Association of Specialists in Ultrasound Diagnostics in Medicine and Russian Society for the Prevention of Noncommunicable Diseases. In the document a definition of focus ultrasound is stated and discussed when it can be used in cardiology practice in Russian Federation.

Goal-directed ultrasound protocol in patients with nontraumatic undifferentiated shock in the emergency department: prospective dual centre study

BACKGROUND AND IMPORTANCE

Early identification of the cause of shock is associated with better prognosis.

OBJECTIVE

The aim of this study was to explore the performances of an ultrasound protocol (echoSHOCK) to diagnose the cause of shock in the emergency department (ED).

DESIGN, SETTINGS AND PARTICIPANTS

This was a prospective study performed in two EDs. Included patients were older than 18 years admitted with shock. After routine workup strategy, the suspected cause of shock and the planned treatment were reported. The echoSHOCK protocol, using only B mode, was then performed. After performing echoSHOCK, the investigator reported the same two items.

INTERVENTION

echoSHOCK protocol that assessed: compressive pericardial effusion (tamponade), right ventricle dilatation and flattening of the septum, left ventricle dimension and systolic function, indices of hypovolemia.

OUTCOMES MEASURE AND ANALYSIS

We defined four different causes for shock (tamponade, acute cor pulmonale, cardiogenic and hypovolemia). The primary endpoint was the degree of agreement of the routine workup and echoSHOCK with an expert panel.

MAIN RESULTS

85 patients [mean age of 73 (14) years] were included. Kappa coefficients between routine strategy and echoSHOCK for the cause of shock, with the expert panel were 0.33 (95% CI, 0.26-0.4) and 0.88 (95% CI, 0.83-0.93), respectively. Likewise, for the planned treatment, kappa were 0.21 (95% CI, 0.14-0.28) and 0.9 (95% CI, 0.85-0.94), respectively. The physician's confidence increased from 3.9 (2.1) before echoSHOCK to 9.3 (1.1) after, (P < 0.001).

CONCLUSION

This study suggested that echoSHOCK significantly increased the ability to determine the cause of undifferentiated shock in the ED.

[Special pathologies of pregnant patients in intensive care medicine]

Da die Inzidenz intensivtherapiepflichtiger Erkrankungen in Schwangerschaft oder Puerperium sehr niedrig ist, werden Intensivmediziner bei der Behandlung dieser Patientinnen vor eine Vielzahl von ungewohnten Herausforderungen gestellt. Die physiologischen und pathophysiologischen Veränderungen während einer Schwangerschaft bedingen einige Besonderheiten bezüglich der intensivmedizinischen Behandlung schwangerer oder kürzlich entbundener Patientinnen. Nachdem im ersten Beitrag dieser CME-Reihe die wichtigsten Prinzipien und aktuellen Empfehlungen zur Versorgung intensivtherapiebedürftiger schwangerer oder frisch entbundener Patientinnen behandelt wurden, fokussiert der zweite Beitrag auf Diagnostik und Therapie spezieller, ausgewählter Krankheitsbilder.

Echocardiographic features of patients with COVID-19 infection: a cross-sectional study

COVID-19 patients with cardiac involvement have a high mortality rate. The aim of this study was to investigate the echocardiographic features in COVID-19 patients between severe and non-severe groups. For this single-center study, data from patients who were treated for COVID-19 between March 25, 2020 and April 15, 2020 were collected. Two-dimensional echocardiography (2DE) images were obtained for all patients. Patients were divided into two groups based on the severity of their COVID-19 infections. 2DE parameters indicating right ventricular (RV) and left ventricular (LV) functions were compared between the two groups. A total of 90 patients hospitalized for COVID-19 were included in this study. The mean age of the severe group (n = 44) was 63.3 ± 15.7 years, and 54% were male. The mean age of non-severe group (n = 46) was 49.7 ± 21.4 years, and 47% were male. In the severe group, RV and LV diameters were larger (RV, 36.6 ± 5.9 mm vs. 33.1 ± 4.8 mm, p = 0.003; LV 47.3 ± 5.8 mm vs. 44.9 ± 3.8 mm, p = 0.023), the LE ejection fraction (LVEF) and the RV fractional area change (RV-FAC) were lower (LVEF, 54.0 ± 9.8% vs. 61.9 ± 4.8%, p < 0.001; RV-FAC, 41.4 ± 4.1% vs. 45.5 ± 4.5%, p < 0.001), and pericardial effusions were more frequent (23% vs. 0%) compared to patients in the non-severe group. A multiple linear regression analysis determined that LVEF, right atrial diameter, high-sensitivity troponin I, d-dimer, and systolic pulmonary artery pressure, were independent predictors of RV dilatation. The results demonstrate that both right and left ventricular functions decreased due to COVID-19 infection in the severe group. 2DE is a valuable bedside tool and may yield valuable information about the clinical status of patients and their prognoses.

Chinese recommendations for the implementation of bedside echocardiography and remote consultation in patients with coronavirus disease 2019

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Feasibility of Anesthesiologist-Performed Preoperative Echocardiography for the Prediction of Postinduction Hypotension: A Prospective Observational Study

Purpose

To determine if left ventricular or inferior vena cava (IVC) measurements are easier to obtain on point-of-care ultrasound by anesthesiologists in preoperative patients, and to assess the relationship between preoperative cardiac dimensions and hypotension with the induction of general anesthesia.

Methods

This prospective observational study was conducted at a large academic medical center. Sixty-three patients undergoing noncardiac surgeries under general anesthesia were enrolled. Ultrasound examinations were performed by anesthesiologists in the preoperative area. To ensure that hypotension represented both a relative and absolute decrease in blood pressure, both a mean arterial pressure (MAP) < 65 mmHg and a MAP decrease of >30% from preoperative value defined this outcome.

Results

Left ventricular measurements were more likely to be acquired than IVC measurements (97% vs. 79%). Subjects without adequate images to assess IVC collapsibility tended to have a higher body mass index (33.6 ± 5.5 vs. 28.5 ± 4.5, p=0.001). While high left ventricular end-diastolic diameter values were associated with a decreased odds of MAP < 65 mmHg (OR: 0.24, 95% CI: 0.07–0.83, p=0.023) or a MAP decrease of >30% from baseline alone (OR: 0.25, 95% CI: 0.07–0.83, p=0.023), the primary endpoint of both relative and absolute hypotension was not associated with preoperative left ventricular dimensions.

Conclusions

Preoperative cardiac ultrasound may be a more reliable way for anesthesiologists to assess patients' volume status compared to ultrasound of the IVC, particularly for patients with a higher body mass index.

Efficacy of a Point-of-Care Transthoracic Echocardiography Workshop for Medical Students

OBJECTIVE

To assess the efficacy of a 5-week point-of-care transthoracic echocardiography workshop for medical students.

DESIGN

Prospective, time-series design.

SETTING

A single institution, including students at one US medical school.

PARTICIPANTS

The study comprised eight second- and third-year medical students.

INTERVENTIONS

Subjects enrolled in a voluntary educational workshop designed to teach basic point-of-care transthoracic echocardiography.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was change on the total examination score (0-100) that assessed hands-on performance of four basic transthoracic echocardiography views, identification of relevant anatomy, and echocardiography knowledge. Secondary outcomes were scores on the practical (0-40) and written (0-60) subsections of the examination. Mean and standard deviation (±SD) total examination scores increased to 83.6 (±5.2) after the workshop versus 54 (±7.1) at baseline (p < 0.0001). Mean (±SD) practical examination scores increased to 38 (±2.5) after the workshop versus 22 (±4.6) at baseline (p < 0.0001). Mean (±SD) written examination scores increased to 46 (±4.8) after the workshop versus 32 (±5.8) at baseline (p = 0.0003).

CONCLUSIONS

Results of this pilot study indicated that the workshop curriculum may be an effective way to teach basic point-of-care transthoracic echocardiography to medical students.

Physiologically Difficult Airway in the Patient with Severe Hypotension and Metabolic Acidosis

The expertise to recognize and manage the difficult airway is essential in anesthesiology. Conventionally, this refers to anatomical concerns causing difficulties with facemask ventilation and/or with tracheal intubation. Severe derangements in patients' physiology can make induction and intubation likewise difficult, and approximately 30% of critically ill patients had cardiovascular collapse subsequently to intubation. We present the case of a 58-year-old male with a past medical history of type II diabetes and hypertension who presented with altered mental status due to severe metabolic acidosis with a pH of 6.8 on admission to the intensive care unit. The anesthesia team was called to urgently intubate the patient. Upon arrival, the patient was localizing to pain and was hypocapnic, tachycardic, and hypotensive despite ongoing therapy with norepinephrine, vasopressin, and bicarbonate drips. Bedside point-of-care ultrasound showed hyperdynamic left ventricle with no other abnormalities. The patient was induced with IV ketamine, and dissociation occurred with maintenance of spontaneous respirations, which was followed by laryngoscopy and intubation causing only minimal hemodynamic changes. The patient was subsequently dialyzed and treated supportively. He was discharged from the hospital two weeks later—neurologically intact and at his baseline. Combination of hypotension and severe metabolic acidosis is particularly a challenging setting for airway management and a major risk factor for adverse events, including cardiopulmonary arrest. Hemodynamically stable induction agents should be preferred. In addition, sustaining spontaneous ventilation and avoiding periods of apnea in the peri-intubation period is paramount—any buildup of CO₂ could push a critically low pH even lower and cause cardiovascular collapse. Sympathomimetic properties of ketamine make this induction agent a particularly appealing choice in this setting. This case report further supports the concept that severe physiologic perturbations—in which conventional induction techniques are not feasible—should be included in the current definition of a difficult airway.

Training and Accreditation Pathways in Critical Care and Perioperative Echocardiography

In recent years, there has been a dramatic rise in the use of echocardiography in perioperative and critical care medicine. It is now recommended widely as a first-line diagnostic tool when approaching patients in shock, due to its ability to identify shock etiology and response to treatment noninvasively. To match the increasing training demand, and to ensure maintenance of high-quality and reproducible scanning, several accreditation pathways have been developed worldwide. Critical care echocardiography training pathways can include both transthoracic and transesophageal scanning and range from basic focused protocols to advanced comprehensive scans. The complexity of each individual training program is reflected in its accreditation process. While basic accreditations may require only course attendance and a relatively brief logbook, comprehensive accreditations often require extensive logbooks and written and practical examinations. Currently, the use of transoesophageal echocardiography remains restricted largely to cardiothoracic anesthesia and critical care; however, its use in the general intensive care setting is growing. This narrative review summarizes the most common training pathways, their curricula, and accreditation requirements. The authors initially focus on echocardiography training in the United Kingdom, and then go on to describe similar international accreditations available in Europe, North America, and Australasia.

Anesthetic considerations for repeat cesarean section

PURPOSE OF REVIEW

The prevalence of cesarean delivery is increasing worldwide despite the advance of Trial of Labor After Cesarean section. In many countries, a history of previous cesarean section is an almost absolute indication for a repeat cesarean section. The purpose of this review was to examine if the perioperative anesthetic management of patients with repeat cesarean section is different from the anesthetic management of patients with primary cesarean section.

RECENT FINDINGS

This review discusses important topics, such as early diagnosis of cases with a potentially high risk for complications; the need for assessment of patients diagnosed with abnormal placentation; the importance of a multidisciplinary approach that includes interaction of the anesthesiologist, gynaecologist, and invasive radiologist; emphasizing the need for reinforcement of new methods of invasive procedures; management of massive bleeding, use of new technologies, and development of an institutional protocol for management of patients with abnormal placentation.

SUMMARY

According to this review, we show that the management of patients with repeat cesarean section without abnormal placentation is almost the same as the management of patients for primary cesarean section. Timely diagnosis of patient with abnormal placentation and multidisciplinary approach is crucial for prevention of morbidity or even mortality.