Services on Demand
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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.60 no.6 Campinas Nov./Dec. 2010
LETTER TO THE EDITOR
The anesthesiologist and the intraoperative transesophageal echocardiography
To the Editor,
I would like the opportunity provided by the article "Changes in Surgical Conduct Due to the Intraoperative Transesophageal Echocardiography" - Sílvio AA et al. 1 - published recently by Revista Brasileira de Anestesiologia to stimulate the discussion regarding the real involvement of the Anesthesiologist in the use of intraoperative transesophageal echocardiography in our country. Countries such, as the United States and Canada, as well as several countries in the European Community, have already incorporated in their services the use of this monitoring device as a means to promote a reduction in morbi-mortality associated with cardiovascular surgical procedures.
I recently read, on a specific chapter on Anesthesiology Clinics 2, that intraoperative transesophageal echocardiography will affect cardiovascular anesthesiology drastically in the near future. Note that the technique, even though rudimentary in the early years, has been used for over 25 years in some departments, and during this period it went through considerable modifications due to technological developments.
We, anesthesiologists, dedicated to cardiovascular anesthesia, consider this technique as a fundamental resource both in the management of the anesthetic technique and hemodynamic control, as well as changes in transoperative decision making by the surgical team along with the anesthetic team 3. Note that intangible actions, but not less important, are related with the development of greater respect and importance of the professional capable of performing a procedure of such specificity, and the aggregated value regarding the remuneration of the procedure.
Several difficulties are associated with the use of intraoperative transesophageal echocardiography; the investment to buy and for maintenance of the equipment, besides the long continuous learning curve.
Besides the very few anesthesiologists with ability and experience with this technique, most likely due to the cost of the monitoring makes it, obligatorily, an institutional method, and the difficulties associated with the formation a qualified professionals, the regulation of intraoperative transesophageal echocardiography by anesthesiologists is very important. Several guidelines to regulate performance of this exam by the anesthesiologist are in place, and accreditation is fundamental; without it, all efforts will be, in general, useless. Acquiring respect and recognition for performing this technique will, undoubtedly, demand efforts.
The American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists (SCA) have publish guidelines 4 elaborated in 1996 by a task force and, due to technological advances and new diagnostic methods developed, not to mention the increasingly decisive results obtained 5, will most likely be reviewed in 2010 or 2011.
Similar example can be found in Canada that has guidelines elaborated in 2006 specifically for intraoperative transesophageal echocardiography performed by anesthesiologists, which was published in the Canadian Journal Anesthesia 6.
Examples do exist in other countries, in which the use of this type of monitoring has been widespread for some time. It is up to Brazilian anesthesiologists to think about it. It will all start with the creation of a certification department with its own guidelines, of well structured evidence levels, and technical stratification of the professional to be qualified, according to the guidelines already in place.
A few models have already been implemented with proven technical-scientific success. We already have an objective. It is up to us, Brazilian anesthesiologists, who dedicate ourselves to cardiovascular anesthesiology and to intraoperative transesophageal echocardiography, to create a model based on our reality.
Kleber Machareth, TSA,
Anesthesiologist of the Anesthesiology Department of
Santa Casa de Campo Grande, MS
01. Silvio AA, Silva ED, Segurado AVR et al. - Mudança de conduta cirúrgica motivada pela ecocardiografia transesofágica intraoperatória. Rev Bras Anestesiol, 2010;60:192-197. [ Links ]
02. Yeates TM, Zimmerman JM, Cahalan MK - Perioperative echocardiography: two-dimensional and three-dimensional applications. Anesthesiol Clin, 2008;26:419-435. [ Links ]
03. Fox J, Glas K, Swaminathan M et al. - The impact of intraoperative echocardiography on clinical outcomes following adult cardiac surgery. Sem Cardioth Vasc Anesth, 2005;9:25-40. [ Links ]
04. American Society of Anesthesiologists - Practice guideline for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists. Task Force on Transesophageal Echocardiography. Anesthesiology, 1996;84:986-1006. [ Links ]
05. Vegas A, Meineri M - Three-dimentional transesophageal echocardiography is a major advance for intraoperative clinical management of patients undergoing cardiac surgery: A core review. Anesth Analg, 2010;110:1548-1573. [ Links ]
06. Beique F, Ali M, Hynes M et al. - 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 Anesth, 2006;53:1044-1060. [ Links ]