Ultrasound: The New Stethoscope (Point-of-Care Ultrasound).

Advances in technology have led to more user-friendly ultrasound devices that allow for easy incorporation into daily perioperative practice, with the anesthesiologist serving as the sonographer. With appropriate knowledge and training, bedside ultrasound examinations can be used to better diagnose pathology and guide perioperative strategies. Cardiac ultrasound examination was the initial emphasis in anesthesiology, with now expansion into lung and gastric ultrasound imaging. In this review, the indications, procedural description, and clinical findings for lung and gastric ultrasound examinations are discussed to demonstrate its importance and build confidence in the user.

Regional Versus Global Measurements of Right Ventricular Strain Performed in the Operating Room With Transesophageal Echocardiography.

OBJECTIVE: To compare regional and global measures of right ventricular (RV) strain in patients undergoing intraoperative transesophageal echocardiography (TEE). DESIGN: Prospective, nonrandomized, observational study. SETTING: Single tertiary-level, university hospital. PARTICIPANTS: The study comprised 48 patients undergoing intraoperative TEE. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A global RV strain measurement (termed RV 5-wall strain [RV 5WS]) was calculated by averaging the longitudinal strain calculated from multiple TEE views. This global strain measurement was compared with the more standard regional strain measurements obtained in a single 4-chamber view (RV free-wall strain [RV FWS] and RV global longitudinal strain [RV GLS]) and with traditional measures of RV function. Regional and global strain measurements were feasible in the operating room. RV FWS and RV GLS strongly correlated with RV 5WS (r = 0.86 and 0.87, respectively) with no significant bias and limits of agreement of approximately -5% to 5%. RV FWS and RV GLS were even more closely correlated with each other (r = 0.99) with no significant bias and limits of agreement less than -2% to 2%. Both regional and global RV strain measurements showed a high sensitivity (RV FWS 94%; RV GLS 94%; RV 5WS 89%) and moderate specificity (RV FWS 70%; RV GLS 67%; RV 5WS 63%) for RV dysfunction based on a reference standard of 3-dimensional RV ejection fraction. CONCLUSIONS: Both regional and global RV strain measurements are feasible in the operating room with TEE. Regional and global measures of RV function correlate well and are sensitive indicators of RV dysfunction.

A Comparison of Left- and Right-Sided Strain Software for the Assessment of Intraoperative Right Ventricular Function.

OBJECTIVE: To compare intraoperative right ventricular (RV) strain measurements made with left ventricular (LV) strain software commonly found on the echocardiography machine (Philips QLAB chamber motion quantification, version 10.7, Philips, Amsterdam, The Netherlands), with offline analysis using the dedicated RV strain software (EchoInsight, version 2.2.6.2230, Epsilon Imaging, Ann Arbor, MI). DESIGN: Prospective, nonrandomized, observational study. SETTING: Single tertiary level, university-affiliated hospital. PARTICIPANTS: The study comprised 48 patients undergoing transesophageal echocardiography for cardiac or noncardiac surgery. INTERVENTIONS: Two-dimensional (2D) and 3-dimensional (3D) images of the right ventricle were obtained. Intraoperative 2D images were analyzed in real time for RV free wall strain (FWS) and global longitudinal strain (GLS) using QLAB chamber motion quantification (CMQ) LV strain software on the echocardiography machine. Two dimensional images were then analyzed offline to determine the RV FWS and GLS using EchoInsight RV-specific strain software. Three-dimensional images were then analyzed offline to detemine the 3D RV ejection fraction (3D RV EF) using TomTec 4D RV function (Unterschleissheim, Germany). Spearman's correlation and Bland-Altman analyses were used to characterize the relationship between RV strain measurements. Both types of strain measurements were compared to a reference standard of 3D RV EF. MEASUREMENTS AND MAIN RESULTS: Intraoperative RV strain measurements using LV-specific strain software correlated with offline RV strain measurements using the RV-specific strain software (FWS rho = 0.85; GLS rho = 0.81). The bias and limits of agreement were 0.75% (- 6.66 to 8.17) for FWS and -4.53% (-11.55 to 2.50) for GLS. The sensitivity and specificity for RV dysfunction for the intraoperative LV-specific software were 94% (95% confidence interval [CI] 73-100) and 70% (95% CI 51-85), respectively, for RV FWS and 94% (95% CI 73-100) and 67% (95% CI 47-83), respectively, for RV GLS. The sensitivity and specificity for RV dysfunction for the offline RV-specific software were 89% (95% CI 65-99) and 73% (95% CI 54-88), respectively, for RV FWS and 94% (95% CI 73-100) and 30% (95% CI 15-49), respectively, for RV GLS. CONCLUSION: Intraoperative RV strain measurements using LV-specific strain software commonly available on the echocardiography machine (QLAB CMQ) correlate with offline RV strain measurements using RV-specific strain software (EchoInsight). The bias and limits of agreement for these left- and right-sided strain software suggest that these 2 measures of RV function cannot be used interchangeably. Both, however, were sensitive measures of RV dysfunction and therefore are likely clinically relevant.

Perioperative safety in coronary artery bypass grafting: the role of the anesthesiologist.

PURPOSE OF REVIEW: As our population ages and cardiovascular disease increases in prevalence, a growing number of patients will be candidates for coronary artery bypass grafting (CABG). Outcomes from this common surgery can be improved by a coordinated team approach involving physicians, nurses, and healthcare professionals from multiple specialties. This review will discuss the role cardiovascular anesthesiologists play in the perioperative care of these complex patients. RECENT FINDINGS: Cardiovascular anesthesiologists may play a variety of important roles throughout the entire perioperative period of patients undergoing CABG. This may include identification and optimization of preoperative comorbidities, employment of enhanced recovery pathways, perioperative echocardiographic assessment of complex cardiovascular states, management of patients on cardiopulmonary bypass, and others. There is growing evidence that each of these areas contributes to better care and improved outcomes. SUMMARY: Care of the patient undergoing CABG requires a team approach. Optimal team dynamics translate into better care for patients and improved outcomes. The cardiovascular anesthesiologist is an integral member of this team whose role is central in the coordination of all aspects of perioperative care. Preoperative optimization begins the process, which continues throughout surgery, cardiopulmonary bypass, and into the postoperative period.

Intraoperative Transesophageal Echocardiography and Right Ventricular Failure After Left Ventricular Assist Device Implantation.

OBJECTIVE: To determine whether intraoperative measures of right ventricular (RV) function using transesophageal echocardiography are associated with subsequent RV failure after left ventricular assist device (LVAD) implantation. DESIGN: Retrospective, nonrandomized, observational study. SETTING: Single tertiary-level, university-affiliated hospital. PARTICIPANTS: The study comprised 100 patients with systolic heart failure undergoing elective LVAD implantation. INTERVENTIONS: Transesophageal echocardiographic images before and after cardiopulmonary bypass were analyzed to quantify RV function using tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (S'), fractional area change (FAC), RV global longitudinal strain, and RV free wall strain. A chart review was performed to determine which patients subsequently developed RV failure (right ventricular assist device placement or prolonged inotrope requirement ≥14 days). MEASUREMENTS AND MAIN RESULTS: Nineteen patients (19%) subsequently developed RV failure. Postbypass FAC was the only measure of RV function that distinguished between the RV failure and non-RV failure groups (21.2% v 26.5%; p = 0.04). The sensitivity, specificity, and area under the curve of an abnormal RV FAC (<35%) for RV failure after LVAD implantation were 84%, 20%, and 0.52, respectively. No other intraoperative measure of RV function was associated with subsequent RV failure. RV failure increased ventilator time, intensive care unit and hospital length of stay, and mortality. CONCLUSION: Intraoperative measures of RV function such as tricuspid annular plane systolic excursion, tricuspid annular systolic velocity, and RV strain were not associated with RV failure after LVAD implantation. Decreased postbypass FAC was significantly associated with RV failure but showed poor discrimination.

The Nuts and Bolts of Performing Focused Cardiovascular Ultrasound (FoCUS).

The benefit of focused cardiovascular ultrasound as an adjunct to physical examination has been shown in numerous specialties and in diverse clinical settings. Although the value of these techniques to the practice of anesthesiology is substantial, they have only begun to be incorporated. This article reviews the basic techniques required to perform a bedside focused cardiovascular ultrasound (ie, FoCUS examination). This includes a discussion of patient positioning, breath control, probe position, and manipulation and was supplemented by normal and abnormal examples for review.

Why Anesthesiologists Must Incorporate Focused Cardiac Ultrasound Into Daily Practice.

The size, availability, cost, and quality of modern ultrasound devices have, for the first time in modern medicine, enabled point-of-care ultrasound by the noncardiologist physician. The appropriate application of focused cardiac ultrasound (FoCUS) by anesthesiologists has the potential to alter management and affect outcomes for a wide range of patients. In this article, the indications, benefits, and limitations of FoCUS are described. The training and equipment required to perform FoCUS are also discussed.