Sasha K. Shillcutt

Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: A report from the american society of echocardiography

General Considerations 40 Scope of Work 41 I. Echocardiographic Hemodynamic Monitoring Tools 41 Two-Dimensional Echocardiographic Monitoring Parameters 42 LV Chamber Dimensions 42 Inferior Vena Cava (IVC) Size and Collapsibility 43 Doppler Monitoring Parameters 43 Mitral Inflow 43 TDI 43 Calculated Monitoring Parameters 44 SV, Cardiac Output (CO), and SVR Calculations 44 RV Systolic Function 44 PA Systolic Pressure 45 II. Advantages, Disadvantages, and Recommendations of Echocardiography as a Monitoring Tool 45 III. Clinical Scenarios 45 Acute CHF Monitoring 45 Critical Care Monitoring 47 Pericardial Tamponade Monitoring 48 Pulmonary Embolism Therapy Monitoring 48 Prosthetic Valve Thrombosis Monitoring 48 Echocardiographic Monitoring in Trauma 48 IV. Perioperative Medicine 49 Echocardiographic Monitoring During Liver, Kidney, and Lung Transplantation 49

The Safety of Transesophageal Echocardiography in Patients Undergoing Orthotopic Liver Transplantation

OBJECTIVE To evaluate the safety of transesophageal echocardiography for the evaluation and intraoperative monitoring of patients during orthotopic liver transplantation. DESIGN Retrospective observational study. SETTING Tertiary care, university teaching hospital. PARTICIPANTS Patients (n = 116) who underwent intraoperative transesophageal echocardiography during liver transplantation. INTERVENTIONS Intraoperative transesophageal echocardiography during liver transplantation. MEASUREMENTS AND MAIN RESULTS The authors evaluated the safety of intraoperative transesophageal echocardiography in patients undergoing liver transplantation through a retrospective chart review. Complications associated with transesophageal echocardiography use were divided into minor and major complications. Out of 116 patients who underwent intraoperative transesophageal echocardiography, there was one minor and one major complication. The major complication rate was 0.86% (1/116) and the overall complication rate was 1.7% (2/116). There was no statistically significant correlation between pre-transplant sclerotherapy for treatment of varices and intraoperative transesophageal echocardiography-related gastrointestinal bleeding. Although the reported complication rate is higher than what has been quoted in the cardiac literature, intraoperative transesophageal echocardiography during liver transplantation has a low complication rate. CONCLUSIONS Intraoperative transesophageal echocardiography is a relatively safe method of monitoring cardiac performance in liver transplant patients.

Transesophageal Speckle-Tracking Echocardiography Improves Right Ventricular Systolic Function Assessment in the Perioperative Setting

Background: Perioperative evaluation of right ventricular (RV) systolic function is important to follow intraoperative changes, but it is often not possible to assess with transthoracic echocardiographic (TTE) imaging, because of surgical field constraints. Echocardiographic RV quantification is most commonly performed using tricuspid annular plane systolic excursion (TAPSE), but it is not clear whether this method works with transesophageal echocardiographic (TEE) imaging. This study was performed to evaluate the relationship between TTE and TEE TAPSE distances measured with M‐mode imaging and in comparison with speckle‐tracking TTE and TEE measurements. Methods: Prospective observational TTE and TEE imaging was performed during elective cardiac surgical procedures in 100 subjects. Speckle‐tracking echocardiographic TAPSE distances were determined and compared with the TTE M‐mode TAPSE standard. Both an experienced and an inexperienced user of the speckle‐tracking echocardiographic software evaluated the images, to enable interobserver assessment in 84 subjects. Results: The comparison between TTE M‐mode TAPSE and TEE M‐mode TAPSE demonstrated significant variability, with a Spearman correlation of 0.5 and a mean variance in measurement of 6.5 mm. There was equivalence within data pairs and correlations between TTE M‐mode TAPSE and both speckle‐tracking TTE and speckle‐tracking TEE TAPSE, with Spearman correlations of 0.65 and 0.65, respectively. The average variance in measurement was 0.6 mm for speckle‐tracking TTE TAPSE and 1.5 mm for speckle‐tracking TEE TAPSE. Conclusions: Using TTE M‐mode TAPSE as a control, TEE M‐mode TAPSE results are not accurate and should not be used clinically to evaluate RV systolic function. The relationship between speckle‐tracking echocardiographic TAPSE and TTE M‐mode TAPSE suggests that in the perioperative setting, speckle‐tracking TEE TAPSE might be used to quantitatively evaluate RV systolic function in the absence of TTE imaging. HighlightsTTE M‐mode TAPSE and TEE M‐mode TAPSE do not agree, and TEE M‐mode TAPSE should not be used to quantify RV systolic function.Speckle‐tracking echocardiography allows accurate TAPSE measurements for TTE and TEE imaging compared with TTE M‐mode TAPSE.Speckle‐tracking TEE TAPSE could be used to quantify RV systolic function in the perioperative setting when standard TTE methods are not possible.

Liver Transplantation: Intraoperative Transesophageal Echocardiography Findings and Relationship to Major Postoperative Adverse Cardiac Events

OBJECTIVE The primary aim of the study was to describe the most common intraoperative transesophageal echocardiography (TEE) findings during the 3 separate phases of orthotopic liver transplantation (OLT). The secondary aim of the study was to determine if the abnormal TEE findings were associated with major postoperative adverse cardiac events (MACE) and thus may be amenable to future management strategies. DESIGN Data were collected retrospectively from the electronic medical record and institutional echocardiography database. SETTING Single university hospital. PARTICIPANTS A total of 100 patients undergoing OLT via total cavaplasty technique. INTERVENTIONS Intraoperative TEE was performed in all 3 phases of OLT. MEASUREMENT AND MAIN RESULTS TEE findings of 100 patients who had TEE during OLT during the dissection, anhepatic, and reperfusion phases of transplantation were recorded after blind review. Findings then were analyzed to see if those findings were predictive of postoperative MACE. Intraoperative TEE findings varied among the different phases of OLT. Common TEE findings at reperfusion were microemboli (n = 40, 40%), isolated right ventricular dysfunction (n = 22, 22%), and intracardiac thromboemboli (n = 20, 20%). CONCLUSIONS Intraoperative echocardiography findings during liver transplantation varied during each phase of transplantation. The presence of intracardiac thromboemboli or biventricular dysfunction on intraoperative echocardiography was predictive of short- and long-term major postoperative adverse cardiac events.

A comparison of basic transthoracic and transesophageal echocardiography views in the perioperative setting

• Volume 116 • Number 6 www.anesthesia-analgesia.org 1231 INDEX CASE A 62-year-old man recovered for 1 hour in the post-anesthesia care unit following a colectomy. He became acutely hypotensive and hypoxic and did not respond to initial fluid bolus or epinephrine. He has a history of esophageal strictures and dysphagia, precluding the use of transesophageal echocardiography (TEE). A transthoracic echocardiogram (TTE) was performed to evaluate the cause of his hemodynamic instability.

Echocardiography‐Based Hemodynamic Management of Left Ventricular Diastolic Dysfunction: A Feasibility and Safety Study

Patients with left ventricular diastolic dysfunction (LVDD) are at increased risk of postoperative adverse events. The primary aim of this study was to evaluate the safety and feasibility of using echocardiography‐guided hemodynamic management (EGHEM) during surgery in subjects with LVDD compared to conventional management. The feasibility of using echocardiography to direct a treatment algorithm and clinical outcomes were compared for safety between groups.

Perioperative management of two patients with left ventricular assist devices presenting for noncardiac surgery in the prone position.

Ventricular assist devices (VADs) provide mechanical circulatory support for patients with advanced heart failure. Patients with VADs are presenting for noncardiac surgery with increasing frequency. Understanding anesthetic management of patients with VADs is timely and necessary for perioperative physicians. We present 2 patients supported by left VADs who required intraoperative prone positioning, and how transesophageal echocardiography and VAD variables can be used to guide management.

The development of a perioperative echocardiography consult service: the Nebraska experience.

From the *Department of Anesthesiology; and †Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska. The administrative development of a perioperative echocardiography consult service at the University of Nebraska Medical Center was supported by the 2012 Society of Cardiovascular Anesthesiologists Foundation Kaplan Leadership Grant. Address reprint requests to Sasha K. Shillcutt, MD, FASE, 984455 Nebraska Medical Center, Omaha, NE 68198-4455. E-mail: sshillcu@ unmc.edu

Trainee experience and success of urgent airway management.

BACKGROUND There are limited data regarding emergent, non-operating room, intubations performed by all levels of anesthesia residents. This study was a large retrospective review of all non-operating room emergent intubations performed at a single tertiary medical center. The study evaluated the rate of difficult intubations by level of resident training, compared success rates for direct versus video laryngoscopy and evaluated the rate and success of rescue video laryngoscopy following failed direct laryngoscopy. METHODS All emergent non-operating room intubations at a tertiary university medical center from July 1, 2009, to August 1, 2012, were reviewed and all study data were collected from the medical records. Intubations were classified as being initiated with either direct or video methods. The total number of attempts required and the rate of success were compared by resident year and intubation type. RESULTS Out of a total of 788 emergent intubations, 741 were performed by anesthesia residents. The higher level anesthesia residents (CA-2 and CA-3) had a statistically significant decrease in the number of attempts needed when compared to CA-1 residents. Rate of success did not vary by resident training year, but success rates were higher for cases initiated with video laryngoscopy. Among direct initiated cases, 8% failed initial direct laryngoscopy and were then successfully intubated with rescue video laryngoscopy. CONCLUSIONS During emergent, non-operating room intubations, senior level residents used fewer attempts at intubations with direct laryngoscopy. Successful intubation was improved by beginning residents when video laryngoscopy was utilized. Complications were not affected by the presence of the attending anesthesiologist.

Transesophageal Echocardiography Findings Associated with Transvenous Lead Extraction

December 2012 • Volume 115 • Number 6 From the *Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE. Accepted for publication May 7, 2012 Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www. anesthesiaanalgesia.org). Reprints will not be available from the authors. Address correspondence to Sasha K. Shillcutt, MD, Department of Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, NE 68198-4455, Address e-mail to sshillcu@unmc.edu Copyright