Guidelines of the Indian Association of Cardiovascular and Thoracic Anaesthesiologists and Indian College of Cardiac Anaesthesia for perioperative transesophageal echocardiography fellowship examination.

During current medical care, perioperative transesophageal echocardiography (TEE) has become a vital component of patient management, especially in cardiac operating rooms and in critical care medicine. Information derived from echocardiography has an important bearing on the patient’s outcome. The Indian Association of Cardiovascular and Thoracic Anaesthesiologists (IACTA) has promoted the use of TEE during routine clinical care of patients undergoing cardiac surgery. An important mission of IACTA is to oversee training and certify anesthesiologists in the perioperative and intensive care use of TEE. The provision of “Fellowship” is by way of conducting IACTA – TEE fellowship (F‑TEE) examination. This has been done annually for the past 7 years using well‑established curriculums by accredited national and international societies. Now, with the transformation and reconstitution of IACTA education and research cell into the newly formed Indian College of Cardiac Anaesthesia, F‑TEE is bound to meet international standards. To ensure that the examinations are conducted in a transparent and foolproof manner, the guideline committee (formulated in 2010) of IACTA has taken the onus of formulating the guidelines for the same. These guidelines have been formally reviewed and updated since 2010 and are detailed here to serve as a guide to both the examinee and examiner ensuring standardization, efficiency, and competency of the IACTA F‑TEE certification process.

An update on transesophageal echocardiography views 2016: 2D versus 3D tee views.

In 1980, Transesophageal Echocardiography (TEE) first technology has introduced the standard of practice for most cardiac operating rooms to facilitate surgical decision making. Transoesophageal echocardiography as a diagnostic tool is now an integral part of intraoperative monitoring practice of cardiac anaesthesiology. Practice guidelines for perioperative transesophageal echocardiography are systematically developed recommendations that assist in the management of surgical patients, were developed by Indian Association of Cardiac Anaesthesiologists (IACTA). This update relates to the former IACTA practice guidelines published in 2013 and the ASE/EACTA guidelines of 2015. The current authors believe that the basic echocardiographer should be familiar with the technical skills for acquiring 28 cross sectional imaging planes. These 28 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination and adds 5 more additional views, introduced for different clinical scenarios in recent times. A comparison of 2D TEE views versus 3D TEE views is attempted for the first time in literature, in this manuscript. Since, cardiac anaesthesia variability exists in the precise anatomic orientation between the heart and the oesophagus in individual patients, an attempt has been made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.

Practice guidelines for perioperative transesophageal echocardiography: Recommendations of the Indian association of cardiovascular thoracic anesthesiologists.

Transoesophageal Echocardiography (TEE) is now an integral part of practice of cardiac anaesthesiology. Advances in instrumentation and the information that can be obtained from the TEE examination has proceeded at a breath-taking pace since the introduction of this technology in the early 1980s. Recognizing the importance of TEE in the management of surgical patients, the American Societies of Anesthesiologists (ASA) and the Society of Cardiac Anesthesiologists, USA (SCA) published practice guidelines for the clinical application of perioperative TEE in 1996. On a similar pattern, Indian Association of Cardiac Anaesthesiologists (IACTA) has taken the task of putting forth guidelines for transesophageal echocardiography (TEE) to standardize practice across the country. This review assesses the risks and benefits of TEE for several indications or clinical scenarios. The indications for this review were drawn from common applications or anticipated uses as well as current clinical practice guidelines published by various society practicing Cardiac Anaesthesia and cardiology . Based on the input received, it was determined that the most important parts of the TEE examination could be displayed in a set of 20 cross sectional imaging planes. These 20 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination. Because variability exists in the precise anatomic orientation between the heart and the esophagus in individual patients, an attempt was made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.

Intra-operative trans-esophageal echocardiography in congenital heart disease.

Intra-operative trans-esophageal echocardiography (TEE) is an important monitoring and diagnostic tool used during surgery for repair of congenital heart disease. In several studies,TEE has been shown to provide additional intra-cardiac anatomic information. Its ability to be used intra- operatively before and after cardiac repair makes it a unique tool. Before TEE was available for intra-operative use, significant residual abnormalities were frequently not detected. The result was often substantial post-operative morbidity and mortality and sometimes the need for re-operation. According to practice guidelines established by the Society of Cardiovascular Anesthesiologists and the American Society of Anesthesiologists, there is strong evidence for the usefulness of TEE in surgery for congenital heart disease because it significantly improves the clinical outcome of these patients. Before surgical correction, TEE helps confirm diagnosis and spot any additional lesion, while after the surgical correction, it provides baseline parameters for comparison after the surgical correction.

Bispectral index-guided anaesthesia for off-pump coronary artery bypass grafting.

Bispectral index (BIS) monitoring may assist reduction in utilisation of anaesthetic agents during general surgical procedures. This study was designed to test whether the use of BIS monitoring reduces the anaesthetic requirements during off-pump coronary artery bypass grafting (CABG). This prospective - clinical trial was conducted on 40 adult patients undergoing elective off-pump CABG. Patients received either isoflurane or propofol anaesthesia. BIS monitoring, which guided the dose of anaesthetic, was carried out in 50 percent of the patients. The amount of anaesthetic agent (isoflurane or propofol) administered from the start of anaesthesia to the end of surgical procedure was calculated and were compared in four groups of patients - namely Group A (I-no BIS) received isoflurane; end tidal concentration was maintained at 1-1.2% in a low flow technique throughout the procedure, Group B (I-BIS) received isoflurane in a low flow technique; inspired concentration was dictated by BIS value maintained at 50; Group C (P-no BIS) received propofol at a dose range of 4-8 mg/kg/hr and in Group D(P-BIS) the propofol infusion rate was dictated by BIS value maintained at 50. The quantity of isoflurane was significantly less for Group B (I-BIS) as compared with Group A (I-no BIS) (37 +/- 4 vs. 24 +/- 4 ml; p< 0.05) and similarly the amount of propofol infused was significantly less in Group D (P-BIS) as compared with Group C (P-no BIS) (176 +/- 9 vs. 120 +/- 6 ml; p< 0.05). BIS guided anaesthesia reduces the anaesthetic agent required for the performance of off-pump CABG. This can be extrapolated in terms of saving agent and reduced cardiac depression during off-pump CABG.