Rene Allard

Unrecognized tamponade diagnosed pre-induction by focused echocardiography

PurposeWe report a case of unrecognized cardiac tamponade diagnosed pre-induction by focused transthoracic echocardiography (TTE). The value of focused perioperative TTE, the anesthetic implications of Churg-Strauss syndrome, and the diagnosis of cardiac tamponade are discussed.Clinical featuresA 58-yr-old man with a history of severe asymptomatic aortic stenosis presented for elective endoscopic sinus surgery for intractable nasal polyps with recurrent sinusitis. His cardiologist and cardiac surgeon had recommended proceeding with surgery, as aortic valve replacement was not indicated because he was asymptomatic. Prior to induction, a focused TTE was performed by anesthesia in order to document the degree of aortic stenosis, baseline ventricular function, and baseline volume status. This provided a baseline for comparison in case the patient’s hemodynamic status should deteriorate intraoperatively. Unexpectedly, the TTE examination revealed cardiac tamponade. After confirmation of the diagnosis by cardiology, urgent pericardiocentesis was performed. A diagnosis of Churg-Strauss syndrome was ultimately made, and the patient was treated with high-dose prednisone therapy.ConclusionFocused TTE has significant clinical utility for the diagnosis and assessment of hemodynamically significant cardiac conditions, particularly in the complex patient where clinical examination is challenging and echocardiographic findings can have immediate management implications.RésuméObjectifNous rapportons un cas de tamponnade cardiaque non reconnue diagnostiquée avant l’induction grâce à une échocardiographie transthoracique (ÉTT) ciblée. Nous discutons de l’utilité de l’ÉTT périopératoire ciblée, des implications anesthésiques du syndrome de Churg-Strauss et du diagnostic de tamponnade cardiaque.Éléments cliniquesUn homme de 58 ans présentant des antécédents de sténose aortique asymptomatique grave s’est présenté pour une chirurgie endoscopique des sinus non urgente en raison de polypes nasaux réfractaires provoquant des sinusites à répétition. Son cardiologue et son chirurgien cardiaque avaient recommandé d’aller de l’avant avec la chirurgie; en effet, le remplacement de la valve aortique n’était pas indiqué, le patient étant asymptomatique. Avant l’induction, une ÉTT ciblée a été réalisée par l’anesthésiologiste afin d’évaluer le degré de sténose aortique, la fonction ventriculaire de base, et la volémie de base. Ces données constituaient des valeurs de base à utiliser à titre de comparaison au cas où le statut hémodynamique du patient venait à se dégrader pendant l’opération. Contre toute attente, l’examen d’ÉTT a révélé une tamponnade cardiaque. Après confirmation du diagnostic par le cardiologue, une ponction péricardique d’urgence a été réalisée. Finalement, un diagnostic de syndrome de Churg-Strauss a été posé, et le patient a reçu un traitement de prednisone à forte dose.ConclusionL’ÉTT ciblée possède une importante utilité clinique pour le diagnostic et l’évaluation de maladies cardiaques significatives d’un point de vue hémodynamique, particulièrement chez les patients présentant des antécédents complexes, chez lesquels l’examen clinique est difficile et pour lesquels des résultats échocardiographiques peuvent avoir des implications immédiates au niveau de la prise en charge.

Adverse event assessment and reporting in trials of newer treatments for post‐operative pain

Assessment and reporting of adverse events (AEs) in studies of perioperative interventions is critical given the potential for unintended and preventable iatrogenic morbidity and mortality. This focused review evaluated the quality of AE assessment and reporting in acute post‐operative pain treatment trials. Since older analgesics (e.g., opioids, NSAIDs) already have a well‐characterized safety profile, we concentrated on trials of pregabalin and gabapentin as a representative sample of studies where the perioperative safety profile was relatively unknown.

Transesophageal echocardiography of an anomalous circumflex coronary artery: anatomy and implications.

A 74-yr-old man was hospitalized after a non-ST elevation myocardial infarction. The patient was scheduled for bypass grafting after angiography revealed complex left anterior descending coronary artery disease with moderate disease in the circumflex (Cx) and right coronary arteries (RCAs). It was noted that the Cx had an anomalous origin which arose from the RCA (Fig. 1). After induction of general anesthesia and invasive line placement, a transesophageal echocardiography (TEE) probe was placed. An unusual finding was seen in the midesophageal long-axis view almost immediately: an apparent communication between the noncoronary sinus of Valsalva and the left atrium (Fig. 2) (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A26, a midesophageal aortic valve long-axis view showing the anomalous circumflex [arrow] as is follows its retro-aortic course; it gives the appearance of a communication between the noncoronary sinus of Valsalva and the left atrium). However, flow between the chambers could not be demonstrated with color Doppler. On further TEE examination, this proved to be the anomalous Cx previously identified. Although its origin could not be identified, its path could be followed through a retro-aortic course to its usual location in the atrioventricular groove (Fig. 3) (Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A27, from a midesophageal 4-chamber view [with progressive anteflexion of the probe], the course of the anomalous circumflex is delineated as is travels behind the aorta and into the atrioventricular groove). The rest of the

A survey of focused cardiac ultrasonography training in Canadian anesthesiology residency programs

To the Editor, Focused cardiac ultrasonography (FoCUS) is being increasingly used by anesthesiologists, intensivists, and emergency physicians to assess patients in perioperative and acute care settings. Accordingly, FoCUS training has recently been incorporated in many Canadian anesthesiology residency programs. Although a recent study demonstrated that FoCUS training in anesthesiology training programs in the United States is uncommon, little is known about the penetration of FoCUS in Canadian training programs. Given the value of perioperative FoCUS and the likelihood that it may become a mandatory part of residency training, the purpose of this study was to assess the current state of FoCUS training in anesthesiology residency programs in Canada. After local research ethics committee approval was obtained (June 2015), a survey was sent by mail and e-mail to the 17 program directors of Canadian anesthesiology residency training programs in September 2015. Of the 17 surveys sent, 13 (77%) were returned. Among them, 12 (92%) programs thought that FoCUS training should be a mandatory part of residency training. The overall percentage (range) of staff anesthesiologists using FoCUS was 12 (3-25) % across all programs. Staff anesthesiologists who regularly using FoCUS were either exclusively or mainly trained in transesophageal echocardiography (TEE) in ten (77%) departments and equally trained in TEE and transthoracic echocardiography in three (23%) departments. Nine (75%) programs currently have mandatory (n = 3, 25%), elective (n = 3, 25%), or medicine elective (n = 3, 25%) rotations in FoCUS. The remaining three (25%) programs offer teaching in FoCUS but with no formal rotation. Training was supervised exclusively by anesthesiologists in five (42%) programs, by anesthesiologists in combination with cardiologists or intensivists in five (42%) programs, and by cardiologists or intensivists (without involvement of anesthesiologists) in two (17%) programs. Five (42%) programs had set minimum targets for FoCUS studies performed during training. The average (range) target was 49 (25-90) studies. Details of the amount and type of didactic training are presented in the Table. All of the programs with a mandatory rotation had more than 20 hr of didactic training and a required minimum number of studies to be performed. Identified barriers to implementation of a FoCUS program included the lack of manpower (n = 6, 46%), expertise (n = 6, 46%), a standardized curriculum and standardized training requirements (n = 5, 39%), and necessary equipment (n = 4, 31%). At the time of the survey, the availability of FoCUS training in Canadian anesthesiology residency training programs was considerably variable. Program directors do appear, however, to recognize its importance for future anesthesiologists, with a large majority offering formal or elective rotations. Most programs offer at least ten hours of didactic training using a combination of lectures, online resources, bedside teaching, and simulation. Some experts propose that basic FoCUS competence can be achieved with as little as 12 hr of didactic and practical training. These levels are currently being surpassed by a majority of the programs. Although no minimum requirements for training currently exist for perioperative FoCUS, most programs with a formal rotation meet recent critical care G. Mizubuti, MD, MSc R. Allard, MD, FRCPC A. M.-H. Ho, MD, FRCPC, FCCP M. Cummings, MD, FRCPC R. C. Tanzola, MD, FRCPC (&) Department of Anesthesiology & Perioperative Medicine, Queen’s University, Kingston, ON, Canada e-mail: tanzolar@kgh.kari.net

Use of a point-of-view camera and an Apple® iPad to teach direct laryngoscopy to trainees

To the Editor, The ability to teach direct laryngoscopy effectively poses a challenge to medical educators. A key difficulty is the inability of the instructor and trainee to visualize the laryngoscopy field of view simultaneously. The ability of the instructor to see what the trainee is seeing would allow for real-time feedback without interference with the laryngoscopy. This concept was previously described by Levitan who invented a head-mounted video system connected to a monitor for real-time display. Nevertheless, the costs and technical setup associated with Levitan’s ‘‘Airway Cam’’ likely limited its widespread use as a teaching tool. To address these limitations, we have created an alternative solution that is simple, portable, cost effective, and as unobtrusive to the trainee as possible. A JVC ADIXXION GC-XA2 camera (JVC Canada) was used to stream a high resolution video to a fourth generation iPad (Apple Canada) using Wi-Fi connectivity. The camera was mounted on a goggle strap with the field of view calibrated with the learner’s line of sight (Figure A). Real-time imaging was possible using the ADIXXION Sync application (Apple iTunes App Store) (Figure B). We tested this system in a simulation laboratory on a Laerdal Airway Trainer (Laerdal Medical Canada). After two to three minutes of setup, a high-quality image was attained with the Sync application set to maximum zoom on the iPad (Video). The streamed images were of sufficient quality to allow an instructor to provide real-time feedback and guidance with regard to laryngoscope insertion, positioning, and endotracheal intubation. Specifically, there was adequate visualization (without glare) of all relevant airway structures on the iPad screen. The light provided by the laryngoscope alone was sufficient to provide adequate image brightness, and the latency between the laryngoscopic view and the display of streamed video images was less than one second. Using our proposed teaching solution, both a trainee and an instructor’s shared laryngoscopic view would allow for real-time feedback to guide laryngoscopy and intubation. This is an accessible tool, since it is portable and the required equipment is readily available, with the most expensive component being an iPad. Since iPad use amongst physicians and students in academic centres is already high, the camera would likely be the only required purchase (approximately

Pro: Focused Cardiac Ultrasound Should be an Integral Component of Anesthesiology Residency Training

300). The major disadvantage of our solution is that the operator’s line of sight must be kept constant relative to their head position (and therefore the camera position) in order to ensure that the camera displays what the operator sees. Nevertheless, in our view, this approach is still likely to enhance teaching of direct laryngoscopy and endotracheal intubation, since this process tends to be a slow and deliberate procedure. As with any new teaching tool, the instructor may have initial difficulty explaining to the learner how s/he needs to alter the laryngoscopy technique based on the streamed image. We consider this challenge to be similar to that occurring in traditional laryngoscopy instruction and one that would be quickly overcome. Electronic supplementary material The online version of this article (doi:10.1007/s12630-014-0212-z) contains supplementary material, which is available to authorized users.