Emergent limited perioperative transesophageal echocardiography: should new guidelines exist for limited echocardiography training for anesthesiologists?

Abstract

Bedside limited echocardiography, or focused cardiac ultrasound, continues to gain popularity in many emergency rooms, intensive care units, and operating rooms as a rapid method of assessing unstable patients. Effective monitoring of cardiovascular function in conditions like cardiac arrest or near-arrest is the crucial step to guide successful resuscitative efforts. Transesophageal echocardiography (TEE) has emerged as one of the preferred cardiac diagnostic and monitoring modalities in the intraoperative setting due to the fact that it is less invasive than many other monitors, is immediately accessible, and allows for continuous real-time monitoring of cardiac function. However, the minimum training requirements needed for the anesthesia provider to obtain the competency, knowledge, and skills for basic certification in perioperative TEE far exceed those developed for other medical specialties. We believe there is an urgent need to develop (1) practical guidelines for emergent perioperative TEE use for anesthesiologists and (2) a requisite educational curriculum to teach the basic skills necessary to aid in the diagnosis and treatment of cardiac arrest or near-arrest scenarios. The measures elucidated in this report summarize the efforts of the Department of Anesthesiology at the University of Florida in establishing the necessary steps to make this process not only practical, but accessible to all trainees. We hope that these collective efforts will provide more trainees the confidence in utilizing TEE to aid in establishing a diagnosis in critical situations.

Keywords

transesophageal echocardiography / curriculum / competency training / hemodynamic instability

References

[1] Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato K, McKenney MG, Nerlich ML, Ochsner MG, Yoshii H. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma1999; 46(3): 466–472

[2] Pershad J, Myers S, Plouman C, Rosson C, Elam K, Wan J, Chin T. Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics2004; 114(6): e667–e671

[3] Melamed R, Hanovich S, Shapiro R, Sprenkle M, Ulstad V, Leatherman J. Limited bedside echocardiography performed in the MICU. Chest2005; 128: 207S

[4] Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr2010; 23(12): 1225–1230

[5] ACCP Certificate of Completion Critical Care Ultrasonography Program. Available at: http://www.chestnet.org/accp/accp-certificate-completion-critical-care-ultrasonography-program (Accessed on <month>January</month><day>9</day>, 2012)

[6] Lucas BP, Candotti C, Margeta B, Evans AT, Mba B, Baru J, Asbury JK, Asmar A, Kumapley R, Patel M, Borkowsky S, Fung S, Charles-Damte M. Diagnostic accuracy of hospitalist-performed hand-carried ultrasound echocardiography after a brief training program. J Hosp Med2009; 4(6): 340–349

[7] Razi R, Estrada JR, Doll J, Spencer KT. Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure. J Am Soc Echocardiogr2011; 24(12): 1319–1324

[8] Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation2010; 122 (18 Suppl 3): S729–S767

[9] Weiss SJ, Savino J. The time is ripe. J Cardiothorac Vasc Anesth2006; 20(6): 765–767

[10] Lin T, Chen Y, Lu C, Wang M. Use of transoesophageal echocardiography during cardiac arrest in patients undergoing elective non-cardiac surgery. Br J Anaesth2006; 96(2): 167–170

[11] Goins KM, May JM, Hucklenbruch C, Littlewood KE, Groves DS. Unexpected cardiovascular collapse from massive air embolism during endoscopic retrograde cholangiopancreatography. Acta Anaesthesiol Scand2010; 54(3): 385–388

[12] Song JE, Chun DH, Shin JH, Park C, Lee JY. Pulmonary thromboembolism after tourniquet inflation under spinal anesthesia: a case report. Korean J Anesthesiol2010; 59(Suppl): S82–S85

[13] Newkirk L, Vater Y, Oxorn D, Mulligan M, Conrad E. Intraoperative TEE for the management of pulmonary tumour embolism during chondroblastic osteosarcoma resection. Can J Anaesth2003; 50(9): 886–890

[14] Ebner FM, Paul A, Peters J, Hartmann M. Venous air embolism and intracardiac thrombus after pressurized fibrin glue during liver surgery. Br J Anaesth2011; 106(2): 180–182

[15] Wei J, Yang HS, Tsai SK, Hsiung MC, Chang CY, Ou CH, Chang YC, Lee KC, Sue SH, Chou YP. Emergent bedside real-time three-dimensional transesophageal echocardiography in a patient with cardiac arrest following a caesarean section. Eur J Echocardiogr2011; 12(3): E16

[16] Blaivas M. Transesophageal echocardiography during cardiopulmonary arrest in the emergency department. Resuscitation2008; 78(2): 135–140

[17] Patteril M, Swaminathan M. Pro: intraoperative transesophageal echocardiography is of utility in patients at high risk of adverse cardiac events undergoing noncardiac surgery. J Cardiothorac Vasc Anesth2004; 18(1): 107–109

[18] Schulmeyer MC, Santelices E, Vega R, Schmied S. Impact of intraoperative transesophageal echocardiography during noncardiac surgery. J Cardiothorac Vasc Anesth2006; 20(6): 768–771

[19] Younker D, Reeves-Viets JL, Gopinath SP, Tsai PI, Moon TL, Cuzick LM. Cardiac arrest upon induction of general anesthesia: transesophageal echocardiography-assisted diagnosis of impending paradoxical embolus. Anesthesiology2009; 111(3): 679–680

[20] Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation2010; 122(18 Suppl 3): S829–S861

[21] Collard CD. Con: intraoperative transesophageal echocardiography is not of utility in patients at high risk of adverse cardiac events undergoing noncardiac surgery. J Cardiothorac Vasc Anesth2004; 18(1): 110–111

[22] Piercy M, McNicol L, Dinh DT, Story DA, Smith JA. Major complications related to the use of transesophageal echocardiography in cardiac surgery. J Cardiothorac Vasc Anesth2009; 23(1): 62–65

[23] Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr2010; 23(11): 1115–1127, quiz 1220–1221

[24] Davis-Gomez N, Perkins GD. Safety of transoesophageal echocardiography during cardiac arrest. Resuscitation2008; 79(1): 175

[25] van der Wouw PA, Koster RW, Delemarre BJ, de Vos R, Lampe-Schoenmaeckers AJ, Lie KI. Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol1997; 30(3): 780–783

[26] Aronson S, Butler A, Subhiyah R, Buckingham RE Jr, Cahalan MK, Konstandt S, Mark J, Ramsay J, Savage R, Savino J, Shanewise JS, Smith J, Thys D. Development and analysis of a new certifying examination in perioperative transesophageal echocardiography. Anesth Analg2002; 95(6): 1476–1482

[27] Memtsoudis SG, Rosenberger P, Loffler M, Eltzschig HK, Mizuguchi A, Shernan SK, Fox JA. The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery. Anesth Analg2006; 102(6): 1653–1657

[28] Hoole SP, Falter F. Evaluation of hypoxemic patients with transesophageal echocardiography. Crit Care Med2007; 35(8 Suppl): S408–S413

[29] Vellayappan U, Attias MD, Shulman MS. Paradoxical embolization by amniotic fluid seen on the transesophageal echocardiography. Anesth Analg2009; 108(4): 1110–1112

[30] Karski JM. Transesophageal echocardiography in the intensive care unit. Semin Cardiothorac Vasc Anesth2006; 10(2): 162–166

[31] The National Board of Echocardiography. Exams & Certifications. Available at: http://www.echoboards.org (Accessed on <month>January</month><day>9</day>, 2012)

[32] American College of Emergency Physicians. Policy Statement. Emergency Ultrasound Guidelines. Approved <month>October</month>2008. Appendix 3-Emergency Medicine Residency Ultrasound Education Guidelines. Available at: http://www.aium.org/publications/guidelines/acepGuidelines.pdf (Accessed on <month>June</month><day>29</day>, 2012)

[33] Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quiñones MA, Cahalan MK, Savino JS. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg1999; 89(4): 870–884

Acknowledgements

Support for this work was provided through the Department of Anesthesiology at the University of Florida.

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2014 Higher Education Press and Springer-Verlag Berlin Heidelberg