José L. Díaz-Gómez

Role of Anesthesia for Endovascular Treatment of Ischemic Stroke Do We Need Neurophysiological Monitoring

The use of acute endovascular stroke intervention was called into question after the results of 2 negative stroke endovascular trials (Interventional Management of Stroke 3 [IMS-3] and Systemic Thrombolysis for Acute Ischemic Stroke per the Stroke Center registry [SYNTHESIS]).1,2 However, the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trial3 compared patients with acute stroke with proximal anterior circulation artery occlusions with usual stroke care, including intravenous tissue-type plasminogen activator (tPA). The study demonstrated a favorable shift in outcomes in the interventional group by modified Rankin Scale (mRS) by 90 days (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.21–2.30). Improvement in mRS was noted for all categories except for death. General anesthesia (GA) was used in 38% of the patients in the interventional group of MR CLEAN. In contrast, 9% of the patients in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE)4 trial received GA. The rate of functional independence (mRS, 0–2 by 90 days) was higher in the intervention group (53.0% versus 29.3%; P <0.01). Furthermore, lower mortality rate was seen in intervention group (10.4 versus 19.0; P =0.04). A recent meta-analysis by Fargen5,6 included MR CLEAN and the prior endovascular stroke trials and suggested a favorable shift outcome (mRS, 0–2; good outcome by 90 days; OR, 1.67; 95% CI, 1.29–1.16; P =0.0001) for patients with large-vessel occlusions who receive interventional therapy. In a post hoc analysis of MR CLEAN for use of GA, Berkhemer reported at the International Stroke Conference in Nashville, TN, a favorable effect when non-GA was used instead of GA (mRS, 0–2 at 90 days 38% versus 23%; P =0.013).7 Also, GA was associated with delayed initiation of interventional therapy in comparison with …

National Certification in Critical Care Echocardiography: Its Time Has Come

Critical Care Medicine www.ccmjournal.org 1801 A NEW ERA IS UPON US The National Board of Echocardiography (NBE) engaged the National Board of Medical Examiners to develop and administer a critical care echocardiography (CCE) examination. Eight medical societies are collaborating to develop examination infrastructure and material. The societies include the Society of Critical Care Medicine (SCCM), American Society of Echocardiography (ASE), Society of Cardiovascular Anesthesiologists, American College of Chest Physicians, American Thoracic Society, American College of Emergency Physicians, Canadian Critical Care Society, and World Interactive Network Focused on Critical Ultrasound. The NBE anticipates offering the CCE examination to eligible candidates in January 2019. Candidates will only be required to present a valid medical license (not specialty board certification) in order to take the CCE board examination. This guest foreword summarizes the issues that have led to the examination pathway and poses questions for our critical care community.

A novel semiquantitative assessment of right ventricular systolic function with a modified subcostal echocardiographic view.

The tricuspid annular plane systolic excursion (TAPSE) is a validated measure of right ventricular function; however, the apical echocardiographic window varies and has limitations in intensive care unit (ICU) patients receiving mechanical ventilation or those with underlying disease and air entrapment. We aimed to evaluate the subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) as an alternative to TAPSE in critically ill patients.

Non-atherosclerotic aortic mural thrombus: a rare source of embolism

A 54-year-old man presented to the emergency department with acute left-sided chest pain and left upper quadrant abdominal pain. He had a significant history of squamous cell carcinoma of the lung previously treated with right pneumonectomy who ; is currently receiving adjuvant chemotherapy with cisplatin. Physical examination was remarkable for tachycardia, hypertension and mild abdominal tenderness. CT angiography revealed an aortic mural thrombus in the ascending aorta and aortic arch without dissection, aneurysm or tortuosity of the aorta. In addition, an infarction of the inferior spleen was reported. Given the high risk of surgery for this patient, he was treated conservatively with esmolol and heparin infusion. His subsequent hospital course was uneventful, and he was successfully discharged on enoxaparin therapy that was successively bridged to rivaroxaban treatment. Follow-up transesophageal echocardiography and CT angiography at one month showed no thrombus in the aorta.

Multidisciplinary Perioperative Management of Pulmonary Arterial Hypertension in Patients Undergoing Noncardiac Surgery

Objectives To describe the effect of implementing a contemporary perioperative pulmonary hypertension (PH)–targeted protocol in patients with pulmonary arterial hypertension (PAH) undergoing noncardiac surgery (NCS). Methods The data of consecutive patients with PAH diagnosed by right heart catheterization who underwent NCS between January 1, 2006 and February 9, 2016 were reviewed. Patient demographics, etiology of PAH, clinical features, diagnostic data, utilization of PH-specific medications, and trend of perioperative complications rate were recorded during the study period. Results In the base cohort of 375 patients, 37 had NCS. The mean age at surgery was 62 years. Most patients were women (78%) classified in group 1 PAH. At the time of the surgery, 86% were New York Heart Association functional class III/IV and 97% had American Society of Anesthesiologists classifications 3 and 4. A larger proportion of patients displayed lower PAH risk scores between 2006 and 2011 (P = 0.045). Conversely, a higher percentage of patients exhibited moderately high to very high PAH risk scores between 2012 and 2016 (P = 0.003). Perioperative and anesthetic-related morbidity was 27%, and no difference was observed between either period (P = 0.944). Most of the complications (70%) were related to general anesthesia. Two deaths (5%) occurred in our study group, both during the 2006–2011 period. Conclusions The combination of a multidisciplinary perioperative approach, utilization of novel pulmonary vascular disease–targeted therapy, adequate perioperative optimization, and thoughtful selection of anesthetic technique seems to be a potential strategy to at least maintain similar perioperative outcomes among higher- and lower-risk patients with PAH undergoing NCS.

Acute Cardiac Complications in Critical Brain Disease

Acute cardiac complications in critical brain disease should be understood as a clinical condition representing an intense brain-heart crosstalk and might mimic ischemic heart disease. Two main entities (neurogenic stunned myocardium [NSM] and stress cardiomyopathy) have been better characterized in the neurocritically ill patients and they portend worse clinical outcomes in these cases. The pathophysiology of NSM remains elusive. However, significant progress has been made on the early identification of neurocardiac compromise following acute critical brain disease. Effective prevention and treatment interventions are yet to be determined.

Echocardiographic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care

Proficiency in echocardiography and lung ultrasound has become essential for anesthesiologists and critical care physicians. Nonetheless, comprehensive echocardiography measurements often are time-consuming and technically challenging, and conventional 2-dimensional images do not permit evaluation of specific conditions (eg, systolic anterior motion of the mitral valve, pneumothorax), which have important clinical implications in the perioperative setting. M-mode (motion-based) ultrasonographic imaging, however, provides the most reliable temporal resolution in ultrasonography. Hence, M-mode can provide clinically relevant information in echocardiography and lung ultrasound-driven approaches for diagnosis, monitoring, and interventional procedures performed by anesthesiologists and intensivists. Although M-mode is feasible, this imaging modality progressively has been abandoned in echocardiography and is often underutilized in lung ultrasound. This article aims to comprehensively illustrate contemporary applications of M-mode ultrasonography in the anesthesia and critical care medicine practice. Information presented for each clinical application will include image acquisition and interpretation, evidence-based clinical implications in the critically ill and surgical patient, and limitations. The present article focuses on echocardiography and reviews left ventricular function (mitral annular plane systolic excursion, E-point septal separation, fractional shortening, and transmitral propagation velocity); right ventricular function (tricuspid annular plane systolic excursion, subcostal echocardiographic assessment of tricuspid annulus kick, outflow tract fractional shortening, ventricular septal motion, wall thickness, and outflow tract obstruction); volume status and responsiveness (inferior vena cava and superior vena cava diameter and respiratory variability [collapsibility and distensibility indexes]); cardiac tamponade; systolic anterior motion of the mitral valve; and aortic dissection.

Focused transthoracic echocardiography curriculum for advanced practice providers assures good concordance with intensivists at echocardiography

OBJECTIVE To describe a focused transthoracic echocardiography (FoTE) curriculum for advanced practice providers (APPs) for echocardiography-driven diagnosis of shock in critically ill patients. METHODS Twelve APPs in 4 intensive care units at an academic medical center received didactic sessions on FoTE, including 1-on-1 proctorship with a registered cardiac sonographer. For a period of 6 months the trainees performed individual studies, then they performed FoTE examinations on critically ill patients; their diagnoses were compared with those of experienced intensivists for the same patients. RESULTS After 6 months of multiple steps of training, APPs could acquire good echocardiographic views, achieving a good inter-rater agreement (Cohens κ of 0.745 [95% CI, 0.385-1.0; P < .01]) in the diagnosis of shock when compared to experienced intensivists. CONCLUSIONS Structured FoTE curriculum enables APPs to have reasonably good diagnostic concordance with intensivists in an echocardiography-driven diagnosis of shock in critically ill patients.

Integrated Cardiac and Lung Ultrasound (ICLUS) in the Cardiac Intensive Care Unit

Purpose of ReviewThis review highlights the use of basic lung ultrasound and introduces the concept of integrated cardiac and lung ultrasound (ICLUS) in the care of patients in the cardiac intensive care unit (ICU).Recent FindingsCardiac ultrasound is a fundamental imaging modality that is the gold standard for the diagnosis of cardiac pathology at the bedside. However, the demographics of the modern cardiac ICU are evolving to encompass patients with complex multi-organ system dysfunction in addition to acute cardiovascular disease. Therefore, a more comprehensive diagnostic approach is needed to allow the cardiologist to unravel the potential interplay of multiple pathologic processes. Literature on lung ultrasound has expanded dramatically in recent years as it has proven to be a feasible and accurate exam that provides rapid diagnosis of pulmonary pathology including pneumothorax, pleural effusion, pneumonia, and pulmonary edema. Furthermore, combined cardiac and lung sonography exposes the interaction of circulatory and pulmonary physiology that is central to the diagnosis and management of acute cardiovascular disease. ICLUS provides valuable information for the diagnosis and management of conditions such as respiratory failure, shock, and heart failure.SummaryNumerous studies in recent years have illustrated the utility of lung ultrasound in various clinical settings. Integration of lung and cardiac ultrasound provides the cardiologist with a more holistic examination of the medically complex patients that are admitted to the modern cardiac ICU.

996: FOCUSED TRANSTHORACIC ECHOCARDIOGRAPHY CURRICULUM FOR ADVANCED PRACTICE PROVIDERS IN THE ICU

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Describe the elements of a focused transthoracic (FoTE) echocardiography curriculum for advanced practice providers (APPs), evaluate their performance in acquisition and interpretation of images and determine the concordance between APPs and experienced intensivists during an echocardiographydriven diagnosis of shock in critically ill patients. Methods: Observational, prospective study performed in medical, surgical, cardiothoracic and neurosurgical intensive care units (ICU) at a tertiary teaching hospital. Twelve APPs received a formal curriculum in FoTE. In addition, three experienced intensivists in echocardiography participated in the comparison with APP’s. Participants received didactic sessions on knobology, sonographic anatomy, clinical interpretation of FoTE in shock, and a wet lab with porcine hearts. A proctorship one on one with a registered cardiac sonographer was performed, and low-fidelity simulation sessions were assessed. The APP group echocardiographic findings were compared with experienced intensivists on ultrasound diagnosis of shock in critically ill patients. Cognitive knowledge was evaluated with a written test. Participants were evaluated on their competence for image quality, time to obtain each FoTE view, time to correct diagnosis, and cognitive post-test. The results were analyzed with descriptive statistics. Results: Twelve APPs were able to acquire good echocardiographic views and recognize the cause of shock on the first and second low-fidelity simulation cases with mean times (in seconds) of 156.9 ± 64.2 and 213.2 ± 82.8 respectively. The mean score in cognitive test at the end of training was 24.6 ± 2.4. APP’s achieved a concordance of 0.745 in diagnosis of type of shock in critically ill patients when compared to experienced intensivists. Conclusions: A structured curriculum in FoTE enables APP’s to have reasonably good ultrasound performance and integration of findings and achieved a concordance with intensivests in echocardiography – driven diagnosis of patients in shock.