Focused cardiac ultrasound: is there room for intraoperative use?

The use of ultrasound in anesthetic practice is already well established in regional blockades,¹ for venous access,² and in the perioperative period of heart surgeries through transesophageal echocardiography.³

Recently, the point-of-care ultrasound (POCUS) has expanded dramatically in the areas of intensive care, surgery and emergency medicine and it has been confirmed that its use in perioperative medicine has a much broader potential than that used by our specialty.

Specifically, perioperative ultrasound is well established in the following fields: (1) cardiac; (2) pulmonary; (3) hemodynamic evaluation; (4) abdominal; (5) vascular access; (6) airway; and (7) intracranial pressure evaluation.⁴

Focused cardiac ultrasound is defined as the use of US at the bedside in order to evaluate the unstable patient and, within a specific list of diagnoses, to individualize clinical treatment for a particular situation based on ultrasound findings and with the use of binary and qualitative questions (yes/no – much/little).⁵

It is important, however, to emphasize its difference when compared to formal echocardiographic examination.

The single purpose of focused cardiac ultrasound is to give answer to qualitative questions, being used as a complement to the physical examination in a short time and with a defined objective of evaluating the cause of clinical instability based on a specific list of diagnoses (Table 1), and its intraoperative use by the anesthesiologist is related to lower rates of complications and mortality in high-risk patients.⁶ On the other hand, the formal echocardiographic examination, however abridged it may be, is dependent on an operator trained, enabled, and certified in the acquisition, analysis, and interpretation of the images obtained, in addition to being often used in different clinical situations besides those found in the perioperative period⁷ (Table 2).

Table 1
Indications for focused cardiac US.

Evaluation of hemodynamic instability

Evaluation of PCR causes

Evaluation of patients at risk for cardiac complications

Table 2
Differences between focused cardiac US and echocardiographic examination.

Formal echocardiography

Training and qualification in the acquisition and interpretation of images

Advanced knowledge in the use of US technology

Focused cardiac US

Specific and limited objective

Basic knowledge on the use of US and its perioperative application

The literature shows that its management is quickly learned and easily acquired,⁸ but it needs to be continually practiced.⁹ The question that now arises is how to incorporate this skill in our field if there is no formal model of anesthesiologist training, capacitation, and certification, whether during residency or already professionally active.⁸

Ideally, POCUS training should be done in the same way as those used for cardiovascular anesthesiologist training in transesophageal perioperative echocardiography,⁹ based on a robust program composed of theoretical classes, training in simulators and living models.

It is time for the anesthesiologist to explore and further incorporate this ability with the use of ultrasound and add it to those already mastered (peripheral blocks, venous accesses) in order to ally the use of this technology to better care for patients in general and, particularly, for severely ill patients.

References

• ¹
  Gray AT. Ultrasound-guided regional anesthesia: current state of the art. Anesthesiology. 2006;104:368-73.
• ²
  Wu SY, Ling Q, Cao LH, Wang J, Xu MX, Zeng WA. Real-time two-dimensional ultrasound guidance for central venous cannulation: a meta-analysis. Anesthesiology. 2013;118:361-75.
• ³
  Shore-Lesserson L, Moskowitz D, Hametz C, et al. Use of intraoperative transesophageal echocardiography to predict atrial fibrillation after coronary artery. Anesthesiology. 2001;95:652-8.
• ⁴
  Mahmood F, Matyal R, Skubas N. Perioperative ultrasound training in anesthesiology: a call to action. Anesth Analg. 2016;122:1794-804.
• ⁵
  Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26:567-81.
• ⁶
  Holm JH, Frederiksen CA, Juhl-Olsen P, Sloth E. Perioperative use of focus assessed transthoracic echocardiography (FATE). Anesth Analg. 2012;115:1029-32.
• ⁷
  Schnobrich DJ, Olson AP, Broccard A, Duran-Nelson A. Feasibility and acceptability of a structured curriculum in teaching procedural and basic diagnostic ultrasound skills to internal medicine residents. J Grad Med Educ. 2013;5:493-7.
• ⁸
  Ramsingh D, Rinehart J, Kain Z, et al. Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents. Anesthesiology. 2015;123:670-82.
• ⁹
  Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26:921-64.

Publication Dates

• Publication in this collection
  Sep-Oct 2018

History

• Published
  19 June 2018