Audit of cardiac pathology detection using a criteria-based perioperative echocardiography service.

Transthoracic echocardiography is often used to screen patients prior to non-cardiac surgery to detect conditions associated with perioperative haemodynamic compromise and to stratify risk. However, anaesthetists' use of echocardiography is quite variable. A consortium led by the American College of Cardiology Foundation has developed appropriate use criteria for echocardiography. At Joondalup Hospital in Western Australia, we have used these criteria to order echocardiographic studies in patients attending our anaesthetic pre-admission clinic. We undertook this audit to determine the incidence of significant echocardiographic findings using this approach. In a 22-month period, 606 transthoracic echocardiographic studies were performed. This represented 8.7% of clinic attendees and 1.7% of all surgical patients. In about two-thirds of the patients, the indication for echocardiography was identified on the basis of a telephone screening questionnaire. The most common indications were poor exercise tolerance (27.4%), ischaemic heart disease (20.9%) and cardiac murmurs (16.3%). Over 26% of patients studied had significant cardiac pathology (i.e. moderate or severe echocardiographic findings), most importantly moderate or severe aortic stenosis (8.6%), poor left ventricular function (7.1%), a regional wall motion abnormality (4.3%) or moderate or severe mitral regurgitation (4.1%). Using appropriate use criteria to guide ordering transthoracic echocardiography studies led to a high detection rate of clinically important cardiac pathology in our perioperative service.

Evaluation of the interpretative skills of participants of a limited transthoracic echocardiography training course (H.A.R.T.scan course).

Limited transthoracic echocardiography performed by treating physicians may facilitate assessment of haemodynamic abnormalities in perioperative and critical care patients. The interpretative skills of one hundred participants who completed an education program in limited transthoracic echocardiography were assessed by reporting five pre-recorded case studies. A high level of agreement was observed in ventricular volume assessment (left 95%, right 96%), systolic function (left 99%, right 96%), left atrial pressure (96%) and haemodynamic state (97%). The highest failure to report answers (that is, no answer given) was for right ventricular volume and function. For moderate or severe valve lesions, agreement ranged from 90 to 98%, with failure to report <5% in all cases except for mitral stenosis (18%). For mild valve lesions, the range of agreement was lower (53 to 100%) due to overestimation of severity. Medical practitioners who completed the structured educational program showed good agreement with experts in interpretation of valve and ventricular function.

Breast reconstruction with a free DIEP (TRAM) flap complicated by cardiac tamponade and arrest: a case report.

Breast reconstruction with free-tissue transfer is now well established and provides excellent aesthetic results. There has been an increasing swing in the literature in the use of internal mammary vessels as the preferred recipient vessels for this procedure. We present a case of a hitherto undocumented life-threatening complication related to the use of these vessels.

Hyponatremia and weight changes in an ultradistance triathlon.

OBJECTIVE: To describe the weight changes and the incidence of hyponatremia during an ultradistance triathlon in the athletes who attend medical care after the race. DESIGN: Descriptive research. SETTING: The 1996 New Zealand Ironman Triathlon in which each athlete swam 3.8 km, cycled 180 km, and ran 42 km. PARTICIPANTS: Ninety-five athletes attending for medical care after the race were studied. One hundred sixty-nine athletes who did not attend for medical care were also weighed before and after the race. MAIN OUTCOME MEASURES: Weights were measured at race registration and on finishing the race. Whole-blood sodium concentration was measured in those athletes with clinical evidence of fluid or electrolyte disturbances. RESULTS: Weights were significantly decreased at the end of the race in the athletes seeking medical care (n = 48, mean % delta wt = -2.5%, p < 0.001) and also in the athletes who did not seek medical care (n = 169, mean % delta wt = -2.9%, p < 0.001). Seventeen percent of race starters sought medical attention. Dehydration accounted for 26% of primary diagnoses and hyponatremia for 9%. One athlete with hyponatremia (Na 130 mEq/L) is described who drank 16 L over the course of the race, with a weight gain of 2.5 kg. This is consistent with the hypothesis of fluid overload as the cause of his hyponatremia. Hyponatremia accounted for four of five admissions to the hospital after the race. An inverse relationship between postrace sodium concentrations and percentage change in body weight was observed (r = -0.63). CONCLUSIONS: Hyponatremia is an important risk to the health of athletes competing in an ultradistance triathlon, with fluid overload the likely aetiology.