Core Review

Copyright © 2012 International Anethesia Research Society. Unauthorized reproduction of this article is prohibited.Copyright © 2012 International Anethesia Research Society. Unauthorized reproduction of this article is prohibited.XXX 2012 • Volume X • Number X www.anesthesia-analgesia.org 1

Author affiliations are provided at the end of the article.

Accepted for publication July 3, 2012.

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. anesthesia- analgesia.org).

See Disclosures at end of article for Author Conflicts of Interest.

Reprints will not be available from the authors.

Address correspondence to Colin F. Royse, MBBS, MD, FANZCA, Department of Surgery, The University of Melbourne, 245 Cardigan St., Carlton, Victoria, Australia, 3053. Address e- mail to [email protected].

Copyright © 2012 International Anesthesia Research SocietyDOI: 10.1213/ANE.0b013e31826a79c1

“An invasion of armies can be resisted, but not an idea whose time has come.”

—Victor Hugo

REVIEW STRUCTUREIn this review, we describe the evolution of physician- performed ultrasound in anesthesia and critical care medi-cine, including the relevance of developments in technology. The concept of an expertise pyramid and levels of proficiency are discussed. Uses of point- of- care ultrasound are detailed for transesophageal echocardiography (TEE), transthoracic echocardiography (TTE), lung ultrasound, vascular access, regional anesthesia, and goal- focused TTE. The final section addresses training and future directions.

ULTRASOUND FOR NONCARDIOLOGISTS—WHERE DID IT START?The first ultrasound machines were developed in the 1950s, based on sonar technology developed in World War II.1 Over the next 3 decades, this technology was developed commercially and became widely adopted by cardiologists, radiologists, and obstetric physicians. The equipment was bulky and very expensive, and the imaging was of relatively poor quality compared with today’s standards. This limited

the technology to major facilities such as diagnostic labo-ratories or the cardiac surgery operating room. Ultrasound entered anesthesiology practice in the late 1980s with the introduction of intraoperative TEE for cardiac surgery.2 Paradoxically, this delayed the widespread adoption of ultrasound into anesthesiology practice because of the inva-sive nature of TEE and its complications.3,4 The requirement for sedation or anesthesia, and the need for a high level of diagnostic knowledge by the cardiac anesthesiologists5,6 equivalent to cardiologists tended to exclude physicians who wished to use ultrasound at a more qualitative level. Those unable to perform a full cardiologist level diagnostic study were considered inadequately trained and therefore should be prevented from accessing the technology. Thus, perioperative echocardiography was seen as the domain of the expert, who generally was the cardiac anesthesiologist.

Smaller, robust, less- expensive, yet high- quality ultra-sound machines were a necessary precursor to greater use of ultrasound, but equally important was a mindset change to consider surface ultrasound applications, including TTE and ultrasound- guided procedures, as important areas for noncardiac anesthesiologists. In parallel, but somewhat delayed in time, other acute care specialties adopted similar changes in view and ultrasound usage.

The changing role of ultrasound can be viewed in evolu-tionary terms. The early stage is when discreet ultrasound examinations are performed by diagnostic laboratories, usually by technologists and reported by cardiologists or radiologists, and the treating clinician subsequently reviews a written report. These tend to be comprehen-sive examinations that are interpreted in- depth by highly trained physicians, but with often considerable delay in delivery of the information to the treating physician. The middle stage is the current practice of point- of- care ultra-sound examination. The big transition has been the use of ultrasound at the point- of- care by the treating physician

Core Review: Physician- Performed Ultrasound: The Time Has Come for Routine Use in Acute Care MedicineColin F. Royse, MBBS, MD, FANZCA,*† David J. Canty, MBBS, FANZCA, PGDipEcho,*‡§|| John Faris, MBChB, DAvMed, FAFOM, FFOM, FANZCA, BA, ASCeXAM, PGDipClinUs,¶#**†† Darsim L. Haji, MBChB, FACEM, PGDipEcho,‡‡ Michael Veltman, MBBS, FANZCA, ASCExam, FASE,¶#**§§ and Alistair Royse, MBBS, MD, FRACS, FCSANZ||||

The use of ultrasound in the acute care specialties of anesthesiology, intensive care, emer-gency medicine, and surgery has evolved from discrete, office- based echocardiographic examinations to the real- time or point- of- care clinical assessment and interventions. “Goal-focused” transthoracic echocardiography is a limited scope (as compared with comprehen-sive examination) echocardiographic examination, performed by the treating clinician in acute care medical practice, and is aimed at addressing specific clinical concerns. In the future, the practice of surface ultrasound will be integrated into the everyday clinical practice as ultrasound- assisted examination and ultrasound- guided procedures. This evolution should start at the medical student level and be reinforced throughout specialist training. The key to making ultrasound available to every physician is through education programs designed to facili-tate uptake, rather than to prevent access to this technology and education by specialist craft groups. There is evidence that diagnosis is improved with ultrasound examination, yet data showing change in management and improvement in patient outcome are few and an impor-tant area for future research. (Anesth Analg 2012;X:•••–•••)

E CORE REVIEW ARTICLE

Copyright © 2012 International Anethesia Research Society. Unauthorized reproduction of this article is prohibited.


2 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA

rather than by a cardiology or radiology service. In car-diac anesthesiology, this involves comprehensive TEE during the operation by the anesthesiologist. For the acute care specialties, this includes goal- focused TTE7 and TEE, ultrasound- guided regional anesthesia8 (including neuraxial9,10 and truncal11 blocks), vascular access,12 and lung13 and pleural scans.14 For the emergency physician, this could also include the FAST abdominal scan (Focused Assessment with Sonography for Trauma).15 The next stage of evolution will be when we incorporate ultrasound into everyday practice rather than performing separate ultra-sound examinations, i.e., ultrasound- assisted examina-tion and ultrasound- guided procedures. Consequently, goal- focused TTE becomes “ ultrasound- assisted examina-tion of the heart,” a lung scan becomes “ ultrasound- assisted examination of the chest,” whereas nerve blocks, vascular access, and pleural drainage become “ ultrasound- guided procedures.” With this evolution, the range and uses of ultrasound will expand dramatically to improve exami-nation of the abdomen, joints, legs (for deep vein throm-bosis), airway, and examinations to help guide physicians during resuscitation and trauma. Expertise in ultrasound by the anesthesiologist may also be useful in assisting the surgeon intraoperatively for direct organ imaging such as of the aorta, liver, kidneys, and lymph nodes, because the skill set of ultrasound use and knowledge is transferable to examination of other body areas. Equally, the surgeon may use the same skill set preoperatively when assessing the patient, or transfer these techniques for direct imaging of internal organs during the operation by placing the probe in a sterile sheath.

THE ROLE OF TECHNOLOGY IN THE EVOLUTION OF ULTRASOUND USEThere is little doubt that advances in ultrasound technol-ogy including reduced equipment size and price have had a major role in the expansion of its use outside of cardiology or radiology. The concept of limited training and the “ultra-sound stethoscope” is not new, but required small, portable technology with adequate image fidelity.

The first generation of portable devices (large desktop computer–sized machines built into a console with wheels) were used principally for TTE and general ultrasound in patients in intensive care, who were too sick to transport to other departments. Inferior imaging ability made more difficult by mechanical ventilation mostly limited their use to abdominal, pelvic, and vascular ultrasound or to office- based TTE. The second generation mobile machines were smaller (laptop computer sized and detachable from a trolley) and had improved imaging capability, nota-bly harmonic imaging, which was a key step forward in mobile TTE. Unfortunately, further miniaturization into hand- carried ultrasound (HCU) systems weighing typi-cally <6 pounds had inferior image quality and lacked echocardiographic modalities used for quantification (par-ticularly spectral pulsed and continuous wave Doppler). There was a greater risk of missing clinically important pathology than by cart- based systems, and this raised con-cern that the use of this technology could lead to patient harm. A position paper was released by the American

Society of Echocardiography in 2002, cautioning practi-tioners to restrict the level of interpretation to the ability of the HCU device.16 This position statement was remark-able in that it predicted many developments that have occurred since then. Importantly, the American Society of Echocardiography task force endorsed the concept of ultrasound- assisted examination stating that it “believes that this technology will extend the concept of the ‘com-plete physical examination,’ allowing more rapid assess-ment of cardiovascular anatomy, function, and physiology.” Furthermore, the evolution of portable ultrasound systems was predicted: “Because the small HCU device may evolve into a full diagnostic device, its use and dissemination will not rest simply on the size of the instrument but on the indi-vidual user and his or her understanding of and response to the information imparted.” In a more recent position paper on focused cardiac ultrasound in the emergent set-ting,17 the American Society of Echocardiography acknowl-edged the use of HCU in ultrasound- assisted examination by noncardiologists. The consensus group recommended choice of ultrasound platform to be “scaled” to the exper-tise of the operator and intended uses, including noncar-diac (e.g., vascular, abdominal, pelvic), which may not be available yet in the HCU devices. The predictions in 2002 have largely been correct with regard to the enormous tech-nological advancement, such that the portable machines of today are fully capable echocardiography systems capable of multiple imaging applications. The limitations imposed by technology in 2002 are largely irrelevant in 2012. In very recent times, however, there has been introduction of even smaller ultrasound systems, capable of fitting into a coat pocket or palm. This latest evolution holds the greatest promise for integration of ultrasound into bedside exami-nation, because of the enhanced portability. However, as in 2002, these HCU devices have limited abilities and the evidence of their utility is still emerging.

THE EXPERTISE PYRAMIDThe concept of an expertise pyramid is shown in Figure 1. Ultrasound- assisted examination is at the broad base of the pyramid, and it is envisaged that the majority of acute care specialists should be able to obtain this level of exper-tise. At the top of the pyramid are the highly trained and qualified experts in ultrasound. It is likely that high- level expertise will be restricted to one specific area, such as echo-cardiography (TTE or TEE), abdominal ultrasound, or chest ultrasound, and will include specialists from acute care disciplines as well as radiologists and cardiologists. The achievement of high- level expertise will be dependent on the level of ultrasound training rather than traditional spe-cialist craft groups. The middle of the pyramid is a space where physicians may develop moderately advanced skill and knowledge in a specific area (such as TTE) with good general knowledge and skills in ultrasound. It is also a tran-sition zone, as practitioners start at the ultrasound- assisted examination level, increase the expertise to become a “good basic sonographer” before ultimately becoming “an expert.” It is envisaged that supervision and mentorship will be pro-vided by practitioners who are at one level higher in experi-ence than the trainee.

Copyright © 2012 International Anethesia Research Society. Unauthorized reproduction of this article is prohibited.Copyright © 2012 International Anethesia Research Society. Unauthorized reproduction of this article is prohibited.

Routine Physician- Performed Ultrasound

XXX 2012 • Volume X • Number X www.anesthesia-analgesia.org 3

Video 1. Parasternal long- axis view showing a normal heart.

Video 2. Parasternal short- axis view showing a normal heart.

Video 3. Parasternal long- axis view showing aortic stenosis.

Video 4. Parasternal short- axis view showing aortic stenosis.

Video 5. Parasternal long- axis view showing right ventricular failure.

Video 6. Parasternal short- axis view showing right ventricular (RV) failure. Note the appearance of the RV and left ventricle (LV) as “a pair of eyes” looking at you, and indicating a large RV. Note also the “D” shape of the LV.

The concept of an expertise pyramid is widely incor-porated into recommendations by learned societies and accreditation bodies on what is required to achieve com-petency. A summary of these recommendations is shown in Table 1. The majority of published recommendations are heavily focused on number of cases performed and various levels of supervision, and requirement for examinations. There are some recommendations in which knowledge and practical skills are separated, for example, the diploma

of diagnostic ultrasound by the Australian Institute of Ultrasound. Achieving competency in knowledge (as dis-tinct from practical skill) is tested either via an examina-tion process or via completion of approved short courses. The Australian and New Zealand College of Anaesthetists’ recommendation, PS46 for TEE competency, is an example




of this for which there are multiple pathways available for achieving the knowledge base.a These include recognized fellowships, the University of Melbourne Postgraduate Diploma course, or completion of the NBE PTEeXAM.

Intensive CareRecently, several roundtable consensus statements have been published on recommendations for ultrasound use by intensive care physicians, which define competencies and support the concept of the expertise pyramid. Mayo et al.18 report on consensus definitions for general and cardiac ultrasound, including basic and advanced applications, and the competencies required to achieve each level. The International Expert Statement on training standards for critical care ultrasonography19 was a consensus of 29 societ-ies, and recommended categories of general ultrasound and basic and advanced cardiac ultrasound. There was com-plete agreement among the participants that general critical care ultrasound and “basic” critical care echocardiogra-phy should be mandatory in the curriculum of intensive care unit (ICU) physicians. Volpicelli et al.20 reported on a consensus agreement on the implementation of lung ultra-sound. The ideal training pathway for physician- performed ultrasound, irrespective of the modality and scope of prac-tice, would include supervised acquisition and assess-ment of knowledge base, practical skill, and interpretation of images. Ultimately, the specific pathways for achiev-ing competence will be determined by specialist societies and credentialing requirements for practice at individual institutions.

AnesthesiologyFor anesthesiology, the historical development of ultra-sound use excluded the majority of practitioners. The major problem with the expertise pyramid is that echocardiogra-phy started with TEE for cardiac surgery, which required a full diagnostic level of knowledge and expertise to be gained in the first instance. Essentially, the pyramid was turned upside down so that one had to be at the top of the pyramid in expertise to commence using the technology. This had the

profound effect of limiting opportunity for noncardiac anes-thesiologists to adopt the technology, because the time and effort to achieve competency was well beyond their clinical scope or opportunity. Furthermore, in the operating room, TEE rapidly became “the domain of the cardiac anesthesiol-ogist,” whereas TTE and other surface ultrasound applica-tions remained the domain of cardiologists and radiologists.

This paradigm, however, is changing with the incor-poration of point- of- care ultrasound use.21 In this middle stage of evolution, point- of- care applications that are well established include ultrasound- guided regional anesthesia, goal- focused TTE (e.g., Hemodynamic Echocardiography Assessment in Real Time [HEART] scan22 or Focused Assessed Transthoracic Echocardiography [FATE]23), and abdominal scanning for trauma (e.g., Focused Assessment with Sonography in Trauma [FAST]15 or Rapid Ultrasound in Shock [RUSH]24) with other uses, such as lung imaging,25 deep vein thrombosis assessment,26 and soft tissue injury27 assessment, developing as the emerging uses. A summary of named goal- focused studies is shown in (Table 2). Importantly, there is a change in emphasis toward accept-ing a limited knowledge base and use of pattern recog-nition of pathology, and a reduced number of cases in training to achieve competence for goal- focused examina-tion. This has facilitated the uptake of ultrasound technol-ogy at a basic level by a much wider group of acute care specialists. Goal- focused echocardiography, however, is not intended to be a state- of- the- art, comprehensive echo-cardiography assessment, but is about identifying clini-cally important cardiac pathology to determine whether patients are at risk for hemodynamic compromise and to guide specific hemodynamic treatment.

Ultimately, broad- base integration of ultrasound technology into clinical practice requires teaching and acceptance at a medical school level, and this is gain-ing popularity. An ultrasound curriculum was success-fully implemented across all 4 years of medical school at the University of South Carolina School of Medicine in 2006.28 The curriculum was based on a point- of- care pro-gram that was developed for emergency medicine physi-cians with a broad coverage of ultrasound specialties. It was well received by the students and teachers, and simi-lar programs have since been increasingly implemented at other institutions from the entire curriculum29 to shorter

Figure 1. The “expertise pyramid.” Four lev-els of expertise are shown, starting with ultrasound- assisted examination, suitable for all physicians, and the “star” at the top of the pyra-mid representing teachers, supervisors of train-ing, or heads of echocardiography laboratories. TEE = transesophageal echocardiography; TTE = transthoracic echocardiography.

a ANZCA Professional Document PS46 Recommendations for Training and Practice of Diagnostic Perioperative Transoesophageal Echocardiography in Adults, 2004.




Table 1. Society- Defined Guidelines for Training and Achieving Competence in Echocardiography

Country–organization Level of training Scope Studies performed/reviewed

Assessment

Anesthesiology (intraoperative TEE)

USA–NBA/SCA Basic Monitoring 50/100 TEE Basic PTEeXAM

Advanced Diagnostic +150 TEE Advanced PTEeXAM

UK/Europe–ACTA/EACTA Advanced Comprehensive and perioperative TEE

125 TEE75 TEE if already accredited

for TTE

125 reports + 5 with images, supervisor reports and exam

Australia/NZ–ANZCA Advanced Diagnostic 100/100 TEE initial+30/50 per year to maintain

competency

One of the following:• Diploma of Clinical

Ultrasound• Advanced PTEeXAM• Diploma of Diagnostic

Ultrasound• Recognized fellowship

in TEE

Cardiology (TTE + TEE), not intraoperative TEE

USA–ASE TTELevel 1 – 3 monthsLevel 2 – 3 monthsLevel 3 – 6 months

Intraoperative TEE as per NBE

Basic TTEComprehensive TTEAble to direct an echo

laboratory

75/75+75/75+150/300

Maintain signed logbookMaintain signed logbookExam—ASCeXAM

UK–BSE TTETEE

250 TTEAs per ACTA above

250 reports, 5 full cases, supervisor reports, and exam

Australia/NZ–Cardiac Society

Acquired during cardiology training

TTETEE

300/300 (50 TEE)+200 per year

Maintain signed logbook No formal assessment

Advanced training (fellowship)

100/100+25 per year

Maintain signed logbook No formal assessment

Radiology

Australia–ASUM DDU – Part 1DDU – Part 2

Specialty specificSpecialty specific

Not specifiedNot specified

Written examWritten + oral exam +5 full case studies

Emergency and intensive care medicine (TEE, TTE + surface ultrasound)

UK–emergency medicine Level 1 Cardiac arrest/shock FAST107/vascular access

50 Maintain signed logbook, competency based assessment

Level 2 (draft) Multiple organ systems 3–5 per week Level 2 not yet established

UK–intensive care General Abdominal, pleural lung, vascular

Not specified For general, basic and advanced echo: logbook with reports verified by a qualified supervisor

Expert round table19,20 Basic echo Basic TTE 30 Certification not mandatory

Advanced echo Fully supervised TTE and fully supervised TEE

150 TTE, 50 TEE

SCA = Society of Cardiovascular Anesthesiologists; NBE = National Board of Echocardiography; TEE = transesophageal echocardiography; PTEeXAM = examination of special competence in advanced perioperative transesophageal echocardiography; ACTA = Association of Cardiothoracic Anaesthetists of Great Britain; EACTA = European Association of Cardiothoracic Anaesthetists; ANZCA = Australian and New Zealand College of Anaesthetists; ASE = American Society of Echocardiography; ASCeXAM = examination of special competence in adult echocardiography; TTE = transthoracic echocardiography; BSE = British Society of Echocardiography; ASUM = Australian Society of Ultrasound Medicine; DDU = Diploma of Diagnostic Ultrasound; FAST = Focused Assessment with Sonography in Trauma.

teaching programs.30–35 The rapid, widespread uptake of ultrasound into undergraduate teaching was presented at the inaugural world congress on ultrasound in medical education in 2011.36

IS USING ULTRASOUND EFFECTIVE?Point- of- care ultrasound examination provides diagnostic information to the clinician, which may aid clinical assess-ment and decision- making, hence ultrasound machines are




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ight

ven

tric

ular

; LA

= le

ft

atriu

m; A

o = a

orta

; AAA

= a

bdom

inal

aor

tic a

neur

ysm

; PEA

= p

ulse

less

ele

ctric

al a

ctiv

ity; P

HT

= p

ulm

onar

y hy

pert

ensi

on; H

CU

= h

and-

carr

ied

ultr

asou

nd; P

W =

pul

sed

wav

e D

oppl

er; C

W =

con

tinuo

us w

ave

Dop

pler

; TH

I =

tissu

e ha

rmon

ic im

agin

g; C

FD =

col

or fl

ow D

oppl

er; E

CG

= e

lect

roca

rdio

gram

; CPD

= c

olor

pow

er D

oppl

er; L

VOT

= le

ft v

entr

icul

ar o

utflo

w tra

ct; A

S =

aor

tic s

teno

sis;

RU

Q =

rig

ht u

pper

qua

dran

t; L

UQ

= le

ft u

pper

qua

dran

t;

DVT

= d

eep

veno

us t

hrom

bosi

s; IV

C =

infe

rior

vena

cav

a.




Tabl

e 3.

Sum

mar

y of

Stu

dies

on

the

Impa

ct o

f Tr

anse

soph

agea

l Ech

ocar

diog

raph

y on

Dec

isio

n- M

akin

g in

Sur

gery

and

Int

ensi

ve C

are

Stu

dyM

etho

dolo

gyIn

fluen

ce o

f TE

E on

man

agem

ent

Com

men

ts

Ane

sthe

siol

ogis

t in

trao

pera

tive

TEE

in a

dult

car

diac

sur

gery

Mis

hra

1998

113

Pros

pect

ive

obse

rvat

iona

l stu

dy in

5016 c

ardi

ac

oper

atio

nsN

ew in

form

atio

n 11.7

% r

esul

ting

in a

cha

nge

in m

anag

emen

t in

25.8

% in

clud

ing

surg

ery

in 1

1.7

% (ne

ed for

gra

ft

revi

sion

0.8

%, I

ABP

0.8

%, o

r in

adeq

uate

val

ve r

epai

r 2.0

8%

)

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Sut

ton

1998

114

Pros

pect

ive

obse

rvat

iona

l stu

dy in

233 c

ardi

ac

oper

atio

nsN

ew in

form

atio

n in

21%

res

ultin

g in

a c

hang

e in

sur

gery

in

10%

Sur

gery

cha

nge

in 6

% o

f pa

tient

s w

here

the

TEE

w

as r

outin

e an

d 22%

whe

n re

ques

ted

by t

he

surg

eon

Clic

k 2000

40

Pros

pect

ive

obse

rvat

iona

l stu

dy in

3245 c

ardi

ac

oper

atio

nsPr

ebyp

ass:

new

info

rmat

ion

in 1

5%

, cha

nged

sur

gery

in 1

4%

; po

stby

pass

: ne

w in

form

atio

n in

6%

, cha

nged

sur

gery

in

4%

Mos

t su

rgic

al c

hang

es w

ere

clos

ure

of p

aten

t fo

ram

en o

vale

. N

o m

ajor

TEE

- rela

ted

GI

com

plic

atio

nsC

outu

re 2

000

42

Pros

pect

ive

obse

rvat

iona

l stu

dy in

851 c

ardi

ac

oper

atio

nsC

hang

e in

man

agem

ent

in 1

4.6

%C

hang

es in

clud

ed m

odifi

catio

n of

med

ical

th

erap

y (5

3%

), su

rgic

al o

pera

tion

(30%

), an

d co

nfirm

atio

n of

dia

gnos

is (27%

).N

owra

ngi 2

001

41

Pros

pect

ive

obse

rvat

iona

l stu

dy in

3245 a

ortic

va

lve

repl

acem

ents

Cha

nge

in s

urge

ry in

14.6

%Ao

rtic

val

ve r

epla

cem

ent

patie

nts

only

Fans

haw

e 2002

37

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 4

30 c

ardi

ac

oper

atio

nsC

hang

e in

sur

gery

(al

l ope

ratio

ns) in

5.6

% a

nd in

ele

ctiv

e C

ABG

cha

nge

3.5

%Fo

rres

t 2002

38

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 2

343 C

ABG

op

erat

ions

Cha

nge

in s

urge

ry in

4.5

%O

nly

CAB

G p

atie

nts

wer

e st

udie

d. T

he G

I co

mpl

icat

ion

rate

att

ribut

able

to

TEE

was

0.0

9%

.Q

addo

ura

2004

39

Pros

pect

ive

obse

rvat

iona

l stu

dy in

474 C

ABG

op

erat

ions

Preb

ypas

s: n

ew in

form

atio

n in

10%

, cha

nged

sur

gery

in

3.4

%; po

stby

pass

: ne

w in

form

atio

n in

3.2

%, c

hang

ed

surg

ery

in 2

%

Onl

y C

ABG

pat

ient

s w

ere

stud

ied.

Eltz

schi

g 2008

115

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 1

2,5

66

card

iac

oper

atio

nsS

urge

ry w

as c

hang

ed in

7%

(pr

ebyp

ass

) an

d 2.2

%

(pos

tbyp

ass)

in a

ll pa

tient

s.A

high

er im

pact

occ

urre

d in

com

bine

d C

ABG

/va

lve

proc

edur

es (12.3

% p

reby

pass

and

2.2

% p

ostb

ypas

s), t

han

isol

ated

val

ve

proc

edur

es (6.3

% p

reby

pass

and

3.3

%

post

bypa

ss) or

CAB

G (5.4

% p

reby

pass

and

1.5

% p

ostb

ypas

s).

Kle

in 2

009

116

Pros

pect

ive

obse

rvat

iona

l stu

dy in

2473 c

ardi

ac

oper

atio

nsC

hang

e in

sur

gery

in 1

5%

Two

serio

us e

soph

agea

l inj

urie

s (1

fat

al) w

ere

due

to T

EE in

sert

ion.

(con

tinue

d)




Stu

dyM

etho

dolo

gyIn

fluen

ce o

f TE

E on

man

agem

ent

Com

men

ts

Ane

sthe

siol

ogis

t in

trao

pera

tive

TEE

in p

edia

tric

car

diac

sur

gery

Kau

shal

1998

117

Obs

erva

tion

stud

y in

300 c

onge

nita

l car

diac

su

rger

y op

erat

ions

Preb

ypas

s: n

ew in

form

atio

n in

5.6

%, c

hang

ed s

urge

ry 3

%;

post

bypa

ss: ch

ange

in s

urge

ry 6

.6%

Use

d to

ass

ess

succ

ess

of s

urgi

cal r

epai

r w

ith

70%

hav

ing

succ

essf

ul r

epai

r, 23.3

% h

avin

g ac

cept

able

res

idua

l def

ects

, and

6.6

% h

ad

mor

e se

vere

def

ects

with

sur

gica

l rev

isio

n re

quire

d in

0.0

3%

. N

o m

ajor

TEE

- rela

ted

GI

com

plic

atio

nsR

ando

lph

2002

118

Pros

pect

ive

obse

rvat

iona

l stu

dy in

1002

cong

enita

l hea

rt s

urge

ry o

pera

tions

Cha

nge

in s

urge

ry 1

3.8

%C

hang

es w

ere

mor

e fr

eque

nt d

urin

g re

oper

atio

ns, v

alve

rep

airs

(ao

rtic

or

atrio

vent

ricul

ar),

and

com

plex

out

flow

tra

ct

reco

nstr

uctio

ns. N

o m

ajor

TEE

- rela

ted

GI

com

plic

atio

nsB

ette

x 2003

119

Pros

pect

ive

obse

rvat

iona

l stu

dy a

t 2 c

ente

rs in

865 c

onge

nita

l car

diac

sur

gery

ope

ratio

nsTE

E le

d to

cha

nge

in d

iagn

osis

in 1

3.8

%, c

hang

ed m

edic

al

ther

apy

in 1

9.4

% a

nd s

urge

ry in

12.7

%M

edic

al c

hang

es in

clud

ed p

harm

acol

ogic

al (1

5.6%

) an

d flu

id m

anag

emen

t (3.

8%).

TEE

findi

ngs

pred

icte

d po

stop

erat

ive

diffi

culti

es in

4.0

%.

Ma

2007

120

Pros

pect

ive

obse

rvat

iona

l stu

dy in

350

cong

enita

l car

diac

sur

gery

ope

ratio

nsPr

ebyp

ass:

new

info

rmat

ion

in 9

.4%

, cha

nged

sur

gery

in

6.6

%; po

stby

pass

: ne

w in

form

atio

n in

16.3

%, c

hang

ed

surg

ery

in 3

.7%

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Ane

sthe

siol

ogis

t in

trao

pera

tive

TEE

in a

dult

non

card

iac

surg

ery

Bra

ndt

1998

121

Pros

pect

ive

obse

rvat

iona

l stu

dy in

66 n

onca

rdia

c op

erat

ions

. In

dica

tions

: he

mod

ynam

ic

inst

abili

ty, p

reop

erat

ive

eval

uatio

n, t

raum

a,

and

hypo

xem

ia

New

find

ings

in 8

0%

lead

ing

to a

cha

nge

in s

urge

ry in

23%

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Kol

ev 1

998

122

Pros

pect

ive

obse

rvat

iona

l stu

dy a

t 7 c

ente

rs in

224 c

ardi

ac a

nd n

onca

rdia

c op

erat

ions

Cha

nge

in m

edic

al m

anag

emen

t in

25%

and

sur

gery

in 4

%Al

l pat

ient

s ha

d pu

lmon

ary

arte

ry c

athe

ter

mon

itorin

g. M

edic

al c

hang

es in

clud

ed fl

uid

ther

apy, v

asoa

ctiv

e in

fusi

ons,

and

dep

th o

f an

esth

esia

.S

uria

ni 1

998

123

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 1

23

nonc

ardi

ac o

pera

tions

Maj

or im

pact

in 1

5%

incl

udin

g a

chan

ge in

tre

atm

ent

of

life-

thre

aten

ing

even

t 7%

, cha

nged

sur

gery

1.6

%, c

hang

ed

intr

aope

rativ

e or

pos

tope

rativ

e m

anag

emen

t 3.2

%

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Den

ault

2002

124

Pros

pect

ive

obse

rvat

iona

l stu

dy in

214

nonc

ardi

ac o

pera

tions

(du

ring

surg

ery

in 1

55

patie

nts,

aft

er s

urge

ry in

PAC

U in

4, a

fter

su

rger

y in

ICU

in 5

5)

Intr

aope

rativ

e ch

ange

s oc

curr

ed in

med

ical

man

agem

ent

in

40%

, and

sur

gery

in 1

8%

.C

hang

es w

ere

intr

aope

rativ

e (2

0%

), in

PAC

U

(1.4

%),

and

in IC

U (18.7

%)

Hof

er 2

004

125

Pros

pect

ive

obse

rvat

iona

l stu

dy in

99 n

onca

rdia

c op

erat

ions

Cha

nge

drug

the

rapy

in 4

7%

and

flui

d th

erap

y in

24%

Hig

her

influ

ence

in fl

uid

ther

apy

for

liver

and

lu

ng t

rans

plan

tatio

n (5

0%

) th

an o

ther

sur

gery

ty

pes

(24%

)S

chul

mey

er

2006

126

Pros

pect

ive

obse

rvat

iona

l stu

dy in

98 n

onca

rdia

c op

erat

ions

Use

ful i

n 98%

of pa

tient

s. In

trao

pera

tive

chan

ges

occu

rred

in

48%

, pos

tope

rativ

e ch

ange

s 25%

, sub

stitu

te for

pu

lmon

ary

arte

ry c

athe

ter

mon

itorin

g 24%

Mos

t fr

eque

nt in

trao

pera

tive

chan

ges

wer

e in

m

edic

atio

n an

d flu

id t

hera

py.

Tabl

e 3.

(Con

tinue

d)

(con

tinue

d)




Stu

dyM

etho

dolo

gyIn

fluen

ce o

f TE

E on

man

agem

ent

Com

men

ts

TEE

in in

tens

ive

care

Oh

1990

127

Pros

pect

ive

obse

rvat

iona

l stu

dy in

49 p

atie

nts

(car

diac

sur

gery

and

non

card

iac)

. In

dica

tions

in

clud

ed a

ortic

pat

holo

gy, e

mbo

lus,

pos

t- AM

I, en

doca

rditi

s.

New

find

ings

in 5

9%

lead

ing

to s

urge

ry in

24%

(fin

ding

s co

nfirm

ed a

t op

erat

ion

in a

ll)N

o m

ajor

TEE

- rela

ted

GI c

ompl

icat

ions

Pear

son

1990

43

Pros

pect

ive

obse

rvat

iona

l stu

dy in

61 p

atie

nts.

In

dica

tions

incl

uded

hem

odyn

amic

inst

abili

ty,

MR

, val

vula

r dy

sfun

ctio

n, e

ndoc

ardi

tis, a

ortic

di

ssec

tion,

and

org

an d

onat

ion.

Cha

nged

man

agem

ent

in 4

4%

lead

ing

to s

urge

ry in

8%

(fi

ndin

gs c

onfir

med

at

oper

atio

n in

all)

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Font

1991

128

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 1

12

patie

nts

(aft

er c

ardi

ac s

urge

ry)

Cha

nged

man

agem

ent

in 1

6%

lead

ing

to c

hang

es in

med

ical

th

erap

y in

4%

and

sur

gery

in 1

2%

(fin

ding

s co

nfirm

ed a

t op

erat

ion

in a

ll)

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Fost

er 1

992

129

Pros

pect

ive

obse

rvat

iona

l stu

dy in

61 p

atie

nts

(car

diac

and

non

card

iac)

. In

dica

tions

: en

doca

rditi

s, e

mbo

lus,

hyp

oten

sion

, MR

, LV

func

tion,

aor

tic d

isse

ctio

n, v

alve

dys

func

tion,

an

d m

isce

llane

ous

Cha

nged

man

agem

ent

in 2

2%

lead

ing

to s

urge

ry in

19%

(fi

ndin

gs c

onfir

med

at

oper

atio

n in

all)

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Rei

cher

t 1992

44

Pros

pect

ive

obse

rvat

iona

l stu

dy in

60 p

atie

nts

in

the

ICU

aft

er c

ardi

ac s

urge

ry w

ith p

ersi

sten

t hy

pote

nsio

n de

spite

PAC

use

New

find

ings

on

TEE

in 5

0%

lead

ing

to a

cha

nge

in

man

agem

ent

incl

udin

g flu

id r

esus

cita

tion

(10%

), su

rger

y fo

r ta

mpo

nade

(2.3

%),

and

no s

urge

ry b

ecau

se o

f ex

clus

ion

of t

ampo

nade

(8.3

%)

Echo

card

iogr

aphy

als

o id

entifi

ed s

ubca

tego

ries

of p

atie

nts

at h

igh

risk

of d

eath

(th

ose

with

si

gns

of r

ight

ven

tric

ular

and

biv

entr

icul

ar

failu

re).

Kho

ury

1993

45

Pros

pect

ive

obse

rvat

iona

l stu

dy in

77 p

atie

nts

(car

diac

and

non

card

iac)

. In

dica

tions

: he

mod

ynam

ic in

stab

ility

, end

ocar

ditis

, em

bolu

s, a

nd a

ortic

dis

sect

ion

Cha

nged

man

agem

ent

in 4

8%

lead

ing

to c

hang

es in

med

ical

th

erap

y in

19%

and

sur

gery

in 2

9%

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Hw

ang

1993

46

Inde

term

inat

e ob

serv

atio

nal s

tudy

in 8

0 c

ritic

ally

ill

pat

ient

s in

the

ICU

(48) an

d em

erge

ncy

depa

rtm

ent

(32). In

dica

tions

incl

uded

ao

rtic

dis

sect

ion,

hem

odyn

amic

inst

abili

ty,

embo

lism

, MR

, and

end

ocar

ditis

.

New

find

ings

in 5

0%

res

ultin

g in

car

diac

sur

gery

in 1

8%

with

co

nfirm

atio

n of

find

ings

at

surg

ery

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Che

nzbr

aun

1994

130

Pros

pect

ive

obse

rvat

iona

l stu

dy in

100 p

atie

nts

afte

r ca

rdia

c su

rger

y. In

dica

tions

incl

uded

ao

rtic

dis

sect

ion,

end

ocar

ditis

, em

bolu

s,

hem

odyn

amic

inst

abili

ty, a

nd m

isce

llane

ous.

Cha

nged

man

agem

ent

in 3

3%

lead

ing

to c

hang

es in

sur

gery

in

16%

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Vig

non

1994

131

Pros

pect

ive

obse

rvat

iona

l stu

dy in

2 c

ente

rs o

n 111 p

atie

nts

in IC

U (m

ixed

pop

ulat

ion)

Ove

rall

chan

ge in

man

agem

ent

due

to T

EE in

36%

incl

udin

g su

rger

y in

8%

. C

hang

e in

man

agem

ent

of 6

6%

in s

hock

ed

patie

nts

No

TEE-

rela

ted

com

plic

atio

ns w

ere

reco

rded

.

Hei

denr

eich

1995

47

Pros

pect

ive

obse

rvat

iona

l stu

dy in

61 p

atie

nts

in

the

ICU

with

hyp

oten

sion

New

find

ings

in 2

8%

(co

mpa

red

with

TEE

) le

d to

sur

gery

in

20%

.N

o m

ajor

TEE

- rela

ted

GI c

ompl

icat

ions

Poel

aert

1995

48

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 1

08

patie

nts

in IC

U (no

car

diac

sur

gery

pat

ient

s).

Indi

catio

ns: he

mod

ynam

ic in

stab

ility

fro

m

card

iac

failu

re o

r se

psis

Of 64%

of pa

tient

s w

ith a

PAC

, 44%

und

erw

ent

ther

apy

chan

ges

afte

r TE

E: 4

1%

in t

he c

ardi

ac a

nd 5

4%

in t

he

sept

ic s

ubgr

oup.

In 4

1%

of pa

tient

s w

ithou

t a

PAC

, TEE

le

d to

a c

hang

e in

the

rapy

.

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Soh

n 1995

49

Pros

pect

ive

obse

rvat

iona

l stu

dy in

127 c

ardi

ac

and

nonc

ardi

ac p

atie

nts

with

hem

odyn

amic

in

stab

ility

Cha

nged

man

agem

ent

in 5

2%

lead

ing

to c

hang

es in

sur

gery

in

21%

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

(con

tinue

d)

Tabl

e 3.

(Con

tinue

d)




Stu

dyM

etho

dolo

gyIn

fluen

ce o

f TE

E on

man

agem

ent

Com

men

ts

Alam

1996

50

Pros

pect

ive

obse

rvat

iona

l stu

dy in

121 p

atie

nts

in t

he IC

U w

ith h

ypot

ensi

onN

ew fi

ndin

gs in

32%

lead

ing

to s

urge

ry in

18%

Sla

ma

1996

132

Pros

pect

ive

obse

rvat

iona

l stu

dy in

61 p

atie

nts

in

a m

edic

al IC

U. In

dica

tions

: sh

ock,

hyp

oxem

ia,

and

endo

card

itis

Cha

nged

man

agem

ent

in 2

1%

lead

ing

to c

hang

es in

med

ical

th

erap

y in

11%

and

sur

gery

in 8

%N

o m

ajor

TEE

- rela

ted

GI c

ompl

icat

ions

McL

ean

1998

133

Pros

pect

ive

obse

rvat

iona

l stu

dy in

53 p

atie

nts

(non

card

iac)

. In

dica

tions

: em

bolu

s, a

orta

, ve

ntric

ular

fun

ctio

n, e

ndoc

ardi

tis, a

nd s

urgi

cal

inve

stig

atio

n

New

find

ings

in 1

1%

, sup

port

ive

findi

ngs

in 3

4%

No

serio

us T

EE c

ompl

icat

ions

wer

e re

cord

ed.

Har

ris 1

999

51

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 2

06

patie

nts

(aft

er c

ardi

ac s

urge

ry) in

whi

ch

the

prin

cipa

l ind

icat

ion

was

hem

odyn

amic

in

stab

ility

New

find

ings

in 4

7%

lead

ing

to c

hang

ed m

anag

emen

t in

32%

in

clud

ing

med

ical

the

rapy

in 1

9%

and

sur

gery

in 3

3%

Wak

e 2001

52

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 1

30

patie

nts

afte

r ca

rdia

c su

rger

y. In

dica

tions

: he

mod

ynam

ic in

stab

ility

, car

diac

thr

ombu

s, o

r ve

geta

tion

Tota

l cha

nge

in 5

8.5

% o

f pa

tient

s; d

rug

ther

apy

in 4

3.3

% a

nd

surg

ery

in 1

5.3

%Th

e TE

E di

agno

sis

supp

orte

d th

e cl

inic

al

diag

nosi

s in

41.5

% o

f pa

tient

s.

Col

reav

y 2002

53

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 2

55

patie

nts

afte

r ca

rdia

c su

rger

y. In

dica

tions

in

clud

ed in

stab

ility

, end

ocar

ditis

, em

bolu

s,

aort

a, a

nd m

isce

llane

ous.

New

find

ings

in 6

7%

of pa

tient

s w

ith h

ypot

ensi

on a

nd c

hang

e in

med

ical

man

agem

ent

and

resu

lting

nor

mot

ensi

on

in 3

1%

, inc

ludi

ng s

urge

ry in

22%

. O

vera

ll m

anag

emen

t ch

ange

in 3

2%

TEE

GI- r

elat

ed c

ompl

icat

ions

incl

uded

or

opha

ryng

eal b

leed

ing

in 1

pat

ient

.

Bru

ch 2

003

54

Pros

pect

ive

obse

rvat

iona

l stu

dy in

115 p

atie

nts

(car

diac

and

non

card

iac)

for

hem

odyn

amic

in

stab

ility

, em

bolu

s, e

ndoc

ardi

tis, v

alve

dy

sfun

ctio

n, a

ortic

dis

sect

ion,

and

tra

uma

Tota

l cha

nge

in 4

3%

of pa

tient

s; m

edic

al t

hera

py in

33%

(m

edic

atio

n an

d flu

id c

hang

es) an

d su

rger

y in

10

% (TE

E fin

ding

s co

nfirm

ed a

t op

erat

ion

in a

ll)

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns.

Hut

tem

ann

2004

55

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 2

16

patie

nts

in IC

U (no

t ca

rdia

c su

rger

y) for

he

mod

ynam

ic in

stab

ility

New

find

ings

in 8

8.4

% le

d to

a c

hang

e in

med

ical

m

anag

emen

t in

68.5

% a

nd s

urge

ry in

5.6

%TE

E G

I com

plic

atio

ns in

clud

ed s

elf- l

imiti

ng

orop

hary

ngea

l ble

edin

g (1

.4%

).

Sch

mid

lin 2

001

56

Ret

rosp

ectiv

e ob

serv

atio

nal s

tudy

in 3

01

patie

nts

afte

r ca

rdia

c su

rger

y. In

dica

tions

in

clud

ed h

emod

ynam

ic in

stab

ility

, sus

pici

on o

f ca

rdia

c ta

mpo

nade

, and

mis

cella

neou

s.

45%

new

find

ings

or

impo

rtan

t fin

ding

exc

lude

d. T

ampo

nade

w

as d

iagn

osed

in 1

1%

and

exc

lude

d in

12%

. C

hang

e in

m

anag

emen

t 73%

ove

rall,

incl

udin

g ph

arm

acol

ogy

and

fluid

s in

40%

, res

tern

otom

y in

14%

, no

rest

erno

tom

y in

13%

, and

mis

cella

neou

s ch

ange

s in

7%

No

maj

or T

EE- re

late

d G

I com

plic

atio

ns

Bre

derla

u 2006

57

Pros

pect

ive

obse

rvat

iona

l stu

dy in

339 p

atie

nts

in IC

U (no

t ca

rdia

c su

rger

y) for

hem

odyn

amic

in

stab

ility

New

find

ings

in 5

6%

led

to a

cha

nge

in m

anag

emen

t in

45%

. N

ew fi

ndin

gs in

clud

ed v

olum

e de

plet

ion

(47%

) an

d re

gion

al w

all m

otio

n ab

norm

aliti

es (27%

) an

d gl

obal

left

ve

ntric

ular

dys

func

tion

(22%

).O

rme

2009

58

Pros

pect

ive

obse

rvat

iona

l stu

dy in

71 p

atie

nts

in IC

U (no

t ca

rdia

c su

rger

y) for

hem

odyn

amic

in

stab

ility

Cha

nge

in m

anag

emen

t in

51.2

% o

f st

udie

s, in

clud

ing

fluid

ad

min

istr

atio

n, in

otro

pe o

r dr

ug t

hera

py, a

nd t

reat

men

t lim

itatio

n

Rep

orte

d co

mpl

icat

ions

are

res

tric

ted

to s

igni

fican

t ga

stro

inte

stin

al (

GI)

trau

ma.

TEE

= t

rans

esop

hage

al e

choc

ardi

ogra

phy;

IAB

P = i

ntra

aort

ic b

allo

on p

ump;

CAB

G =

cor

onar

y ar

teria

l by

pass

gra

ftin

g; I

CU

= i

nten

sive

car

e un

it; P

ACU

= p

osta

nest

hesi

a ca

re u

nit;

MR

= m

itral

reg

urgi

tatio

n; P

AC =

pu

lmon

ary

arte

ry c

athe

ter;

AM

I = a

cute

myo

card

ial i

nfar

ctio

n.

Tabl

e 3.

(Con

tinue

d)




Tabl

e 4.

Sum

mar

y of

Stu

dies

on

the

Impa

ct o

f Tr

anst

hora

cic

Echo

card

iogr

aphy

on

Hem

odyn

amic

Man

agem

ent

and

Dec

isio

n- M

akin

g in

Ane

sthe

sia,

Em

erge

ncy

Med

icin

e, a

nd Int

ensi

ve C

are

Stu

dyM

etho

dolo

gyIn

fluen

ce o

f TT

E on

man

agem

ent

Com

men

ts

Ane

sthe

siol

ogis

t pe

riop

erat

ive

TTE

in n

onca

rdia

c su

rger

yC

anty

2009

74

Pros

pect

ive

obse

rvat

iona

l stu

dy in

87 n

onca

rdia

c su

rger

y pa

tient

s w

here

TTE

was

req

uest

ed b

y th

e tr

eatin

g an

esth

esio

logi

st.

Cha

nges

in m

edic

al m

anag

emen

t in

34%

(h

emod

ynam

ic m

anag

emen

t, an

esth

etic

te

chni

que,

and

pos

tope

rativ

e ca

re) an

d su

rgic

al

man

agem

ent

in 7

% (su

rger

y al

tere

d in

2%

and

de

ferr

ed in

5%

)

TTE

perf

orm

ed b

y si

ngle

ane

sthe

siol

ogis

t (H

EAR

T sc

an). C

hang

es o

ccur

red

in t

he p

reop

erat

ive

asse

ssm

ent

clin

ic (9%

), pr

eope

rativ

e in

ope

ratin

g ro

om (25%

), in

trao

pera

tive

(10%

), an

d PA

CU

(2%

).

Cow

ie 2

011

75

Pros

pect

ive

obse

rvat

iona

l stu

dy in

170

nonc

ardi

ac s

urge

ry p

atie

nts.

Indi

catio

ns

incl

uded

mur

mur

(58%

), he

mod

ynam

ic

inst

abili

ty, v

entr

icul

ar fun

ctio

n, d

yspn

ea, a

nd

poor

fun

ctio

nal c

apac

ity.

Cha

nge

in m

anag

emen

t in

82%

incl

udin

g po

stpo

ned

surg

ery

for

card

iolo

gy T

TE (20%

),

canc

eled

sur

gery

(4%

), pe

riope

rativ

e he

mod

ynam

ic c

hang

es (51%

), an

d le

vel o

f po

stop

erat

ive

care

(7%

)

TTE

perf

orm

ed b

y ca

rdio

vasc

ular

ane

sthe

siol

ogis

ts.

Dia

gnos

tic im

ages

obt

aine

d in

98%

. Ao

rtic

ste

nosi

s in

26%

, pul

mon

ary

hype

rten

sion

in 1

4%

. Fi

ndin

gs

confi

rmed

by

a ca

rdio

logi

sts

in 9

2%

Can

ty 2

012

72

Pros

pect

ive

obse

rvat

iona

l stu

dy in

100

nonc

ardi

ac s

urge

ry p

atie

nts

seen

in t

he

preo

pera

tive

clin

ic. In

dica

tions

incl

uded

su

spec

ted

card

iac

dise

ase

or a

ge >

65 y

.

Cha

nge

in m

anag

emen

t in

54%

incl

udin

g ch

ange

d su

rger

y in

2%

. C

hang

es in

clud

ed a

ste

p up

in

trea

tmen

t in

36%

and

a s

tep

dow

n in

tre

atm

ent

in 8

%.

TTE

perf

orm

ed b

y si

ngle

ane

sthe

siol

ogis

t (H

EAR

T sc

an). H

emod

ynam

ic m

anag

emen

t ch

ange

s in

clud

ed a

nest

hetic

tec

hniq

ue, i

nvas

ive

mon

itorin

g,

and

vaso

pres

sor

infu

sion

. Fi

ndin

gs c

onfir

med

by

a ca

rdio

logi

st in

92%

but

diff

eren

ces

wer

e no

t cl

inic

ally

sig

nific

ant

Can

ty 2

012

73

Pros

pect

ive

obse

rvat

iona

l stu

dy in

99 e

mer

genc

y no

ncar

diac

sur

gery

pat

ient

s. In

dica

tions

in

clud

ed s

uspe

cted

car

diac

dis

ease

or

age

>65 y

.

New

find

ings

in 6

7%

and

cha

nge

in m

anag

emen

t in

44%

incl

udin

g ch

ange

d su

rger

y in

2%

. C

hang

es

incl

uded

a s

tep

up in

tre

atm

ent

in 2

0%

and

a

step

dow

n in

tre

atm

ent

in 3

4%

.

TTE

perf

orm

ed b

y ca

rdio

vasc

ular

ane

sthe

siol

ogis

ts

(HEA

RT

scan

). C

hang

es w

ere

proc

edur

al in

14%

(p

reop

erat

ive

refe

rral

, sur

gery

typ

e, o

r le

vel o

f po

stop

erat

ive

care

) an

d he

mod

ynam

ic m

anag

emen

t ch

ange

s in

30%

(in

vasi

ve m

onito

ring,

flui

d an

d va

sopr

esso

r, an

d an

esth

etic

tec

hniq

ue)

Inte

nsiv

e ca

re

Vig

non

1994

131

Pros

pect

ive

obse

rvat

iona

l stu

dy in

40 n

onca

rdia

c su

rger

y pa

tient

s. In

dica

tions

incl

uded

LV

dysf

unct

ion,

PH

T, R

A th

rom

bus,

per

icar

dial

ef

fusi

on, v

alve

and

pos

tcar

diac

arr

est

LV

asse

ssm

ent.

Cha

nged

man

agem

ent

in 1

6%

. TT

E w

as in

fluen

tial

in p

atie

nts

with

per

icar

dial

effus

ion

(100%

), LV

dy

sfun

ctio

n (7

7.5

%),

and

hypo

tens

ion

(24%

).

TTE

perf

orm

ed b

y in

tens

ivis

ts

Jens

en 2

004

23

Pros

pect

ive

obse

rvat

iona

l stu

dy in

227

nonc

ardi

ac s

urge

ry p

atie

nts

not

mak

ing

clin

ical

pro

gres

s. 6

6%

wer

e m

echa

nica

lly

vent

ilate

d.

New

find

ings

wer

e de

cisi

ve in

24.5

%, s

uppl

emen

tal

in 3

7.3

%, a

nd s

uppo

rtiv

e in

35.6

%.

TTE

was

per

form

ed b

y in

tens

ivis

ts (FA

TE p

roto

col).

D

iagn

ostic

imag

es o

btai

ned

incl

uded

api

cal (

80%

), le

ft p

aras

tern

al (69%

), an

d su

bcos

tal (

58.4

%).

Jose

ph 2

004

66

Pros

pect

ive

obse

rvat

iona

l stu

dy in

100 p

atie

nts

with

sho

ck w

hen

an e

choc

ardi

ogra

m (TE

E) w

as

requ

este

d

TTE

reve

aled

a c

ardi

ac c

ause

of sh

ock

in 6

3%

. S

ensi

tivity

of TT

E fo

r ca

rdia

c ca

use

of s

hock

was

100%

, spe

cific

ity 9

5%

, pos

itive

pre

dict

ive

valu

e 97%

, and

neg

ativ

e pr

edic

tive

valu

e 100%

. Th

ere

wer

e re

lativ

e co

ntra

indi

catio

ns t

o TE

E in

15%

of

case

s.

TTE

was

per

form

ed b

y ca

rdia

c so

nogr

aphe

rs

(com

preh

ensi

ve T

TE). Im

agin

g w

as d

iagn

ostic

in

99%

.

Man

asia

2005

134

Pros

pect

ive

obse

rvat

iona

l stu

dy in

90 c

ardi

ac

and

nonc

ardi

ac s

urge

ry p

atie

nts

New

find

ings

occ

urre

d in

84%

of pa

tient

s le

adin

g to

ch

ange

d m

anag

emen

t in

37%

.TT

E w

as p

erfo

rmed

by

inte

nsiv

ists

with

brie

f tr

aini

ng

(10 h

) in

TTE

, whi

ch w

as c

heck

ed b

y ca

rdia

c so

nogr

aphe

rs. TT

E im

agin

g w

as d

iagn

ostic

in 9

4%

an

d in

terp

rete

d co

rrec

tly in

84%

.

(con

tinue

d)




Stu

dyM

etho

dolo

gyIn

fluen

ce o

f TT

E on

man

agem

ent

Com

men

ts

Sta

nko

2005

135

Pros

pect

ive

obse

rvat

iona

l stu

dy in

126 c

ardi

ac

and

nonc

ardi

ac s

urge

ry p

atie

nts

New

find

ings

led

to c

hang

ed m

anag

emen

t in

41%

of

pat

ient

s. M

ajor

cha

nges

occ

urre

d in

8%

(s

urge

ry c

hang

es o

r ot

her

new

act

ive

trea

tmen

t)

and

min

or c

hang

es in

92%

(m

edic

atio

n ch

ange

s or

ref

erra

l).

TTE

was

per

form

ed b

y ca

rdia

c so

nogr

aphe

rs

(com

preh

ensi

ve T

TE).

Orm

e 2009

58

Pros

pect

ive

obse

rvat

iona

l stu

dy in

187

nonc

ardi

ac s

urge

ry p

atie

nts.

Indi

catio

ns

incl

uded

LV

and

RV

asse

ssm

ent,

infe

ctiv

e en

doca

rditi

s, p

eric

ardi

al e

ffus

ion,

and

pu

lmon

ary

edem

a.

Man

agem

ent

was

cha

nged

in 5

1.2

% o

f pa

tient

s an

d in

clud

ed c

hang

es t

o flu

id

adm

inis

trat

ion,

inot

rope

or

drug

the

rapy

, and

tr

eatm

ent

limita

tion.

The

mai

n im

pact

was

in

hem

odyn

amic

ally

uns

tabl

e pa

tient

s.

TTE

was

per

form

ed b

y in

tens

ivis

ts. D

iagn

ostic

imag

es

wer

e ob

tain

ed in

91.3

% o

f sp

onta

neou

sly

brea

thin

g an

d 84.2

% o

f m

echa

nica

lly v

entil

ated

pat

ient

s.

Emer

genc

y de

part

men

t TT

EJo

nes

2004

136

Ran

dom

ized

con

trol

led

tria

l of ea

rly v

ersu

s de

laye

d TT

E in

214 p

atie

nts

with

non

trau

mat

ic

hypo

tens

ion

and

sym

ptom

s of

sho

ck (e.

g.,

sync

ope,

dys

pnea

, unr

espo

nsiv

enes

s, fat

igue

)

Early

TTE

incr

ease

d th

e lik

elih

ood

of d

etec

ting

the

corr

ect

diag

nosi

s of

hyp

oten

sion

fro

m 5

0%

to

80%

.

TTE

perf

orm

ed b

y a

third

- yea

r em

erge

ncy

med

icin

e re

side

nt o

r bo

ard-

cert

ified

em

erge

ncy

phys

icia

n

Hau

ser

1989

137

Pros

pect

ive

obse

rvat

iona

l stu

dy in

81 p

atie

nts

with

che

st p

ain

and

nond

iagn

ostic

EC

G

chan

ges

New

find

ings

in 1

6%

led

to a

cha

nge

in d

ispo

sitio

n pl

an in

19%

.TT

E w

as p

erfo

rmed

by

card

iolo

gist

s.

Atar

2004

138

Pros

pect

ive

obse

rvat

iona

l stu

dy in

70 p

atie

nts

with

che

st p

ain

and

nond

iagn

ostic

EC

G

chan

ges

TTE

dete

cted

acu

te c

oron

ary

synd

rom

e w

ith a

se

nsiti

vity

of 100%

, spe

cific

ity o

f 93%

, and

ne

gativ

e an

d po

sitiv

e pr

edic

tive

valu

es o

f 71%

an

d 100%

.

TTE

diag

nosi

s of

acu

te c

oron

ary

synd

rom

e w

as

com

pare

d w

ith d

isch

arge

dia

gnos

is in

clud

ing

trop

onin

T m

easu

rem

ents

.

Bla

iva

2001

139

Pros

pect

ive

obse

rvat

iona

l stu

dy in

169 p

atie

nts

in c

ardi

ac a

rres

t re

ceiv

ing

CPR

No

patie

nt w

ith s

onog

raph

ical

ly id

entifi

ed c

ardi

ac

stan

dstil

l sur

vive

d to

leav

e th

e em

erge

ncy

depa

rtm

ent

rega

rdle

ss o

f th

e in

itial

ele

ctric

al

rhyt

hm.

TTE

was

per

form

ed b

y em

erge

ncy

phys

icia

ns a

nd

trai

nees

. Th

is fi

ndin

g w

as u

nifo

rm r

egar

dles

s of

do

wnt

ime.

Sal

en 2

005

140

Pros

pect

ive

obse

rvat

iona

l stu

dy a

t 4 c

ente

rs in

70 p

atie

nts

with

car

diac

arr

est

rece

ivin

g C

PRPa

tient

s pr

esen

ting

vent

ricul

ar a

kine

sis

did

not

have

ret

urn

of s

pont

aneo

us c

ircul

atio

n re

gard

less

of th

eir

card

iac

rhyt

hm, a

syst

ole,

or

PEA.

TTE

was

per

form

ed b

y em

erge

ncy

phys

icia

ns.

Taya

l 2003

141

Pros

pect

ive

obse

rvat

iona

l stu

dy in

20 p

atie

nts

who

had

PEA

or

near

PEA

Eigh

t pa

tient

s w

ith v

entr

icul

ar a

kine

sis

on T

TE

did

not

reco

ver;

12 p

atie

nts

with

ven

tric

ular

ak

ines

is a

nd 7

with

per

icar

dial

effus

ion

all

surv

ived

to

hosp

ital d

isch

arge

.

TTE

was

per

form

ed b

y em

erge

ncy

phys

icia

ns.

Bla

ivas

2001

142

Pros

pect

ive

obse

rvat

iona

l stu

dy in

103 p

atie

nts

with

dys

pnea

(un

expl

aine

d an

d ne

w o

nset

)Pe

ricar

dial

effus

ion

(13.6

%) an

d pa

tient

dis

posi

tion

wer

e ac

cura

tely

det

erm

ined

by

TTE.

TTE

was

per

form

ed b

y em

erge

ncy

phys

icia

ns.

Liu

2005

108

Pros

pect

ive

obse

rvat

iona

l stu

dy in

103 p

atie

nts

with

car

diom

egal

yTT

E in

crea

sed

diag

nost

ic a

ccur

acy

from

62%

(c

linic

al e

xam

inat

ion)

to

83%

. M

isse

d ca

rdia

c di

agno

ses

wer

e re

duce

d by

60%

.

TTE

was

per

form

ed b

y em

erge

ncy

phys

icia

ns.

Jone

s 2005

143

Pros

pect

ive

obse

rvat

iona

l stu

dy in

103

patie

nts

with

non

trau

mat

ic h

ypot

ensi

on

with

hyp

oten

sion

and

clin

ical

evi

denc

e of

ci

rcul

ator

y sh

ock

TTE

dete

ctio

n of

hyp

erdy

nam

ic L

V fu

nctio

n ha

d a

high

spe

cific

ity (93%

) of

sep

tic s

hock

.TT

E w

as p

erfo

rmed

by

emer

genc

y ph

ysic

ians

and

tr

aine

es.

TTE

= tr

anst

hora

cic

echo

card

iogr

aphy

; HEA

RT

= H

emod

ynam

ic E

choc

ardi

ogra

phic

Ass

essm

ent i

n R

eal T

ime;

PAC

U =

pos

tane

sthe

sia

care

uni

t; F

ATE

= F

ocus

ed A

sses

sed

Tran

stho

raci

c Ec

hoca

rdio

grap

hy; P

HT

= p

ulm

onar

y hy

pert

ensi

on; R

A = r

ight

atr

ial;

LV =

left

ven

tric

ular

; RV

= r

ight

ven

tric

ular

; EC

G =

ele

ctro

card

iogr

am;

CPR

= c

ardi

opul

mon

ary

resu

scita

tion;

PEA

= p

ulse

less

ele

ctric

al a

ctiv

ity.

Tabl

e 4.

(Con

tinue

d)




not considered a therapeutic device. In terms of efficacy, there are 3 aspects to consider: is diagnosis improved, does improved diagnosis lead to change in decision- making, and do changes in decision- making lead to better patient outcome? The controversy starts earlier: even if diagnosis is improved, it is up to the user to decide on subsequent changes, if any, to management.

The last aspect is the most controversial, because even with correct knowledge, the practitioner may not initi-ate appropriate or best therapy. In the literature, there are very few randomized studies or outcome data investi-gating the use of ultrasound in critical care applications. Therefore, in this review, we focus on diagnostic accuracy and decision- making.

TRANSESOPHAGEAL ECHOCARDIOGRAPHYMost of the literature aims to identify the incidence of new findings that were not detected by either clinical or other cardiac tests. There are 2 focus areas: elective use in cardiac surgery, and use in the ICU for hemodynamically compromised patients. A summary of findings is shown in Table 3, consistently reporting the high rate of influences of TEE on diagnosis and management. In cardiac surgery, the use of routine TEE leads to identification of new find-ings sufficient to change the operation in approximately 5% of patients.37–39 Most of these changes relate to a clini-cally relevant difference from preoperative assessment of anatomical abnormalities, such as moderate or severe valve disease. In studies in which TEE was used in selected patients, such as in patients at increased risk or enduring hemodynamic instability, the frequency of change is much higher (14%–21%).40–42

In the ICU, where the principal indication for TEE was hemodynamic compromise, the TEE led to a change in diag-nosis and management in 40% of cases.43–58 The majority of changes were in hemodynamic treatment (vasopressor, inotrope infusions, and fluid management) but a signifi-cant proportion relate to surgical decision- making (such as diagnosis or exclusion of pericardial tamponade and aortic dissection).

On the basis of these observational, and largely proof- of- concept studies, TEE has become incorporated into routine practice in cardiac surgery and postoperative care. Given the potential serious complications of esophageal injury, however, the decision to use TEE must be justified, and approved indications are published by governing bod-ies.59,60 There are, however, no outcome studies in which TEE has been randomized as an intervention to assess patient outcome.

TRANSTHORACIC ECHOCARDIOGRAPHYMost of the literature on the use of TTE outside of cardi-ology laboratories relates to the diagnostic superiority of TTE over clinical examination, especially when performed by novices and with handheld ultrasound technology.61–65 Initially, the literature compared the image quality of held echocardiography with comprehensive systems, and sub-sequently reported its clinical applications. It is this litera-ture that best supports the concept of “ ultrasound- assisted examination.” A common finding was the influence on

clinical management of the new cardiac diagnoses revealed by echocardiography.

A summary of publications in critical care is shown in Table 4. With the recent and considerable improvements in technology, TTE now rivals TEE as the investigation of choice for hemodynamic instability,66 because adequate imaging is now feasible in most mechanically ventilated patients (95%–98%)23,67,68 and is noninvasive. The summa-rized data show frequent changes in diagnosis and man-agement with TTE in patients requiring noncardiac surgery, admission to the ICU, and the emergency department. Taken together, it is apparent that a junior doctor equipped with minimal training in echocardiography and a por-table ultrasound machine will outperform an experienced cardiologist with a stethoscope.69 Vignon et al.70 recently investigated the efficacy of a brief echocardiography train-ing program (12 hours) for intensive care residents, who subsequently demonstrated a high level of competence in diagnosis of basic hemodynamic disorders using TTE. Royse et al.71 evaluated the training course used to teach the HEART scan goal- focused TTE study on interpretation of pathology using recorded videos and found a high agree-ment with course students and experts. Importantly, there are no studies in which clinical examination outperformed echocardiography.

In anesthesiology, there are few data evaluat-ing the effect of echocardiography diagnosis on clini-cal decision- making, and these are mostly series of case reports or proof- of- concept observational studies. However, in patients who have or are at risk of cardiac disease, the detection rate of clinically significant pathol-ogy is in the order of 25% of patients, which leads to changes in perioperative management.72,73 In prospec-tive observational studies by Canty et al.72–74 and Cowie,75 the therapeutic impact from focused TTE was 39% to 82%, which was principally before anesthesia (90%) for noncardiac surgery, but also during and after surgery in mechanically ventilated patients. Important management changes were identification of high cardiac risk patients and alteration in preoperative assessment and level of postoperative care (10%–15%), but surgery was changed for a small proportion of patients (2%) as a result of the new information from TTE. The majority of changes were in hemodynamic management (30%–40%), including more rational use of invasive monitoring and fluid and vaso-pressor use. In a study by Canty et al.,72 during which goal- focused TTE was used in the preadmission clinic setting, the overall effect was to step down planned treat-ment (based on a reassurance from normal TTE findings) in more patients than to step up treatment based on clini-cally significant pathology. The effect on workflow was to reduce the intensity of treatment and resource use. This, however, has not been subjected to economic or outcomes analysis.

These publications mirror the earlier work with TEE, showing strong proof of concept that either goal- focused or comprehensive TTE may change our practice in the pre-admission clinic in a large proportion of patients. The inci-dence of abnormal findings by limited echocardiography is similar to that of comprehensive echocardiography studies in the preadmission setting. Faris et al.76 investigated the




incidence of cardiovascular pathology in patients attend-ing a preadmission clinic, where the indication for TTE was based on appropriate use criteria guidelines issued by the American Society of Echocardiography. They reported that 27.6% of patients considered appropriate for TTE had at least moderate or severe cardiac pathology. However, many of these studies are “proof of concept,” and the clinical use of the new information was determined by the treating cli-nician. Further research is required to determine whether the change in diagnosis or management leads to improve-ment in outcomes.

LUNG ULTRASOUNDLung ultrasound imaging is an emerging discipline that has widespread application to surgery, anesthesiology, and intensive care and has been incorporated into the focused TTE protocols FATE23 and RUSH.24 Certain diagnoses, such as detection of pneumothorax and pleural effusion are widely recognized and easy to obtain.13,25 Pleural effu-sion size is reasonably accurately assessed by measuring pleural fluid dimensions with ultrasound when compared with drainage volume.77,78 The size of pneumothorax can be estimated by measuring the “contact point” where the

probe is moved around the chest to see where the lung joins the pleural space.79 Despite demonstration of improved safety of pleural drainage with point- of- care ultrasound,14,80 uptake into clinical use has been slow.14,81,82 The emerg-ing areas of interest, however, are to correlate lung imag-ing with patterns of pathology such as alveolar- interstitial syndrome83 (including pulmonary edema), consolidation and collapse,84 abscess, emphysema, and even pulmonary embolus.85 Lichtenstein and Meziere13 reported effective and rapid diagnosis of these disorders in critically ill patients with acute respiratory failure using lung ultrasound, dem-onstrating a very high sensitivity and specificity compared with computed tomography. The routine use of lung ultra-sound in critical care has the potential to substitute for com-puted tomography and chest radiography, particularly for repeated examinations, and thus reduce radiation exposure to patients and staff.86

ULTRASOUND- GUIDED VASCULAR ACCESS Real- time use of ultrasound to guide vascular access is well established as a point- of- care application of ultrasound. This is the one area in which there is high- level evidence of benefit, but mostly for internal jugular vein cannulation.

Figure 2. Composite diagram of 3 patients presenting for fractured neck of femur surgery with systolic murmur. Images are from transtho-racic studies performed before anesthesia. The “good case” shows an unrestricted aortic valve (AV) in panel A, and normal left ventricular (LV) size and function in panel B. The murmur is from a sclerotic AV (not shown was absence of mitral regurgitation). The “bad case” shows a severely calcified and restricted AV in panel C but normal LV size and function in panel D. The “ugly case” shows an unrestricted AV, but dilated right ven-tricle (RV) and LV is in panel E, and a dilated RV and D- shaped interventricular septum in panel F, consistent with having severe pulmonary hyper-tension and biventricular failure. The systolic murmur was due to tricuspid regurgitation. The first patient proceeded with no change to man-agement; the second proceeded with arterial line monitoring, vasopressor infusion, and post-operative high- dependency unit; and the third patient had palliative care instead of surgery.




In 2011, a combined task force of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists published recommendations supporting the routine use of ultrasound- guided internal jugular vas-cular access “whenever possible,” which was based on 30 level 1 studies supporting its use.87 The National Institute for Clinical Excellenceb (United Kingdom) published similar rec-ommendations in 2002 and a subsequent audit demonstrated reduced central venous catheter–related complications in 284 patients since its implementation at a single institution.88

ULTRASOUND- GUIDED REGIONAL ANESTHESIAThe use of ultrasound to guide regional blockade is now widely accepted throughout the world. The literature cov-ers 3 phases: the first was to describe how to perform the block and to describe the sonographic anatomy; the second was to show performance advantage such as faster onset of block, less local anesthetic used, or high rate of efficacy; and the third phase was to identify whether it makes a clinical difference such as improved success, longer dura-tion, and reduced morbidity compared with the anatomical landmark or nerve stimulator- guided techniques. Soeding et al.92 demonstrated faster onset and more complete onset of brachial plexus blocks with an ultrasound-guided tech-nique compared with blind technique. Improved analgesia was reported with ultrasound- guided regional anesthesia in 2 recent meta- analyses.89,90 There was insufficient evi-dence to draw conclusions on improved outcome, but a reduction in surrogate morbidity including vascular punc-ture and diaphragmatic paralysis was demonstrated in the meta- analysis by Neal et al.90 Importantly, there are no reports showing that ultrasound is inferior to blind tech-niques, and significant morbidity from peripheral nerve blockade is very rare.91 Adoption of ultrasound has without doubt led to a rapid expansion in regional blockade in acute and chronic pain medicine and to new techniques including a variety of vertebral (neuraxial),9,10 paravertebral, and trun-cal (e.g., transverses abdominus plane11,93) blocks.

GOAL- FOCUSED TTE: SEPARATING “THE GOOD, THE BAD, AND THE UGLY”The incorporation of goal- focused TTE is perhaps the great-est challenge for anesthesiologists and critical care physi-cians in the next few years. It is also a necessary step in the evolution of clinical ultrasound before it evolves to “ ultrasound- assisted examination.” There are several para-digm shifts that are necessary for widespread adoption of goal- focused TTE. We must accept that novices can perform goal- focused TTE.94 A further paradigm shift is that diag-nosis of pathology is largely based on pattern recognition rather than detailed knowledge base and formal quantifica-tion. This is not full diagnosis, but rather answering clini-cal questions in real time, with referral to more experienced practitioners for full diagnosis at a later stage. An example is the identification of aortic stenosis, whereby pattern recognition can be used to determine clinically important

stenosis, whereas formal quantification to assess the sever-ity requires the use of spectral Doppler particularly. The presence of heavily calcified and restricted aortic valve leaf-lets is one pattern that rapidly identifies potentially clini-cally significant aortic stenosis.

In a study of interpretative ability of novices after a train-ing course to teach the HEART scan, novices reported on 5 videotaped echocardiography cases in which only 2-dimen-sional (2D) and color flow Doppler images were available.71 The agreement between novice and expert was very high for hemodynamic state and valve severity. In particular, few clinically important valve lesions were misdiagnosed, whereas there was a tendency to overcall the severity of mild valve lesions. Using continuous wave Doppler, Cowie and Kluger95 studied the ability of novices to measure peak aortic gradients from the apical 5-chamber view and compared it with that of expert cardiac anesthesiologists. There was very high agreement of significant aortic stenosis (based on valve morphology) and good agreement (based on peak velocity alone (κ 0.8–1), reinforcing the importance of pattern recognition of aortic stenosis on 2D imaging.

In recent years, the concept of portable ultrasound is less relevant because most portable echocardiography systems had all basic echocardiographic modalities and approached cart- based machines in image quality. However, this is not true of the palm- sized echocardiography machines and these may have limitations in their ability to perform goal- focused studies. Furthermore, one must overcome the fear that the clinician may “miss something important” when doing a limited versus comprehensive study, that is, the notion that a missed diagnosis outweighs any positive prospect of new or correct diagnoses. There are 2 polar opinions to this state-ment. One view is that misdiagnosis by ultrasound could lead to patient harm, and the best way to avoid that is to ensure that only practitioners who are expert in perform-ing and interpreting echocardiography are given access to high- level equipment and allowed to perform echocardiog-raphy. The alternative view is that clinical diagnosis is fre-quently incorrect compared with echocardiography, and even accepting that practitioners with limited training and experi-ence will miss or misdiagnose pathology on occasions, that ultrasound- assisted examination will reduce the incidence of incorrect diagnosis compared with physical examination alone,22,65 and that there could be a clinical consequence to not performing echocardiography. Practice is likely to lie between the 2 poles and should be directed by evidence.

The Australian experience may provide insights into the likely mode of adoption and education in ultrasound in acute care medicine. In 2004, the University of Melbourne Postgraduate Diploma of Perioperative and Critical Care Echocardiography was released with the predominant focus on TEE for cardiac anesthesiology, and the major-ity of students had no interest in TTE. In 2012, the course is now in 2 levels: the first level concentrates more on TTE and surface ultrasound but with basic TEE, and the second level is devoted to diagnostic knowledge base and empha-sis on both TTE and TEE. The distribution by specialty is now overwhelmingly in favor of noncardiac acute care specialties, with fewer than 25% of students being cardiac anesthesiologists (personal communication, University of Melbourne Ultrasound Education Group, 2012). The

b NICE. Guidance on the Use of Ultrasound Locating Devices for Placing Central Venous Catheters. Technology Appraisal Guidance No. 49. Avai-lable at: http://www.nice.org.uk/nicemedia/live/11474/32461/32461.pdf. Accessed February 22, 2012.




majority of noncardiac anesthesiologists do not perform TEE and have no interest in it. In North America, the move toward limited echocardiography has been in the form of “basic TEE,” although it is likely that a paradigm shift toward limited TTE will occur given the noninvasive nature of this technology and removal of the need for sedation or anesthe-sia to perform the study.

In general, normal or mild pathology is unlikely to lead to hemodynamic compromise under anesthesia. Examples of “good, bad, and ugly” are shown in Figure 2. Acute care physicians will be reassured if the ejection systolic murmur they heard on auscultation is only aortic sclerosis. However, they will be alerted if it is moderate or severe aortic stenosis, and alarmed if a patient who is short of breath has severe pul-monary hypertension and right heart failure. See online sup-plemental digital content for examples of normal (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A451, and Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A452), aortic stenosis (Video 3, see Supplemental Digital Content 3, http://links.lww.com/AA/A453, and Video 4, see Supplemental Digital Content 4, http://links.lww.com/AA/A454), and right ventricular failure (Video 5, see Supplemental Digital Content 5, http://links.lww.com/AA/A455, and Video 6, see Supplemental Digital Content 6, http://links.lww.com/AA/A456).

There are many published goal- focused studies, and each has a catchy acronym. They range in scope from very simple (2D only) studies to assess ventricular function in a peri- arrest situation (Table 4), to more extensive yet still lim-ited studies incorporating 2D and color flow Doppler to eval-uate valve and ventricular function (HEART scan22,71). The common feature is to concentrate on either 2D only, or 2D and color flow Doppler analysis, and to avoid formal quan-tification using pulsed wave or continuous wave Doppler. Another common feature is an emphasis on pattern recogni-tion of pathology rather than extensive quantification. The scanning ability and level of knowledge required to be pro-ficient in quantification and spectral Doppler is much higher than that required to view 2D imaging, or with color flow Doppler. Removing spectral Doppler also reduces the time

taken to perform the study, such that a goal- focused study can be performed and reported in 10 minutes or less. The ability to discriminate hemodynamically significant from nonsignificant aortic stenosis is important, because it is a significant risk factor for postoperative mortality,96 is poorly assessed clinically,97,98 and may be asymptomatic even if severe.99 This has been achieved by focused TTE performed by anesthesiologists72–74 and others100–102 using 2D assess-ment of valve cusp separation without the use of quantita-tive spectral Doppler (standard with comprehensive TTE).

Although acronym, goal- focused examinations define a particular sequence of study views, the point- of- care physi-cian must ultimately determine what structures to look at first, according to clinical requirement. For example, the subcostal view is most appropriate during an arrest situation because images can be obtained without interrupting chest compression.

HOW DO WE ACHIEVE ULTRASOUND FOR EVERYONE?To achieve full evolution, training in ultrasound should be incorporated into medical school teaching. It should be viewed as part of clinical assessment and examination. There are some centers already adopting this approach.

Within acute care medical disciplines, the logical approach is to start with limited TTE and surface ultra-sound applications, and then to progress up the pyramid of expertise. Learned societies and credentialing organizations should produce guidelines to identify what knowledge is required and how many studies should be performed to ensure competency.18,19 Such recommendations should seek to be consistent across specialty craft groups.

The barriers to adoption of ultrasound for everyone revolve in part around education and equipment. In the past decade, there has been a major shift in focus from static and large cart- based ultrasound machines to portable, yet high- quality, ultrasound systems. Although the cart- based machines are the most sophisticated and provide the best image quality, they are not well suited to many areas of critical care practice. The smaller, portable machines are

Table 5. Examples of iPhone/Android Apps and Educational Websites

Name Type Focus Comment

iASE iPhone/Android Guidelines and normal values Pocket guide. Distributed by American Society of Echocardiography

EchoCalc iPhone/Android Reference values and calculator for quantification

Distributed by the British Society of Echocardiography

Echocardiography i-pocketcards iPhone/Android Atlas and reference guideFocus Pocket Guide iPhone/iPad Aide- memoire for the FOCUS study Describes views and sequenceFate Card iPhone/Android Aide- memoire for the FATE study Describes views, values, and sequencePocketGuide iPhone Ultrasound- guided regional anesthesia Pocket book style, release 2012iHeartScan iPhone/iPad Report form database for the HEART

scanEnter data real time to produce

written report, release 2012e-Echocardiography Website Echocardiography and ultrasound

learning resourceMuch more extensive than iPhone

apps. Offers CME accreditationEcho University Online Website Education to prepare for examinations Target cardiologists and sonographersSociety Websites Websites Many society websites offer

echocardiography educationExamples include SCA and ASE

ASE = American Society of Echocardiography; FOCUS = Focused Cardiac Ultrasound Study; FATE = Focused Assessed Transthoracic Echo; HEART scan = Haemodynamic Echocardiography Assessment in Real Time; CME = Continuing Medical Education; SCA = Society of Cardiovascular Anesthesiologists.




easier to move and position next to patients, whether in the ICU, the anesthesia induction room, or in the preadmission clinic. The cost is also reduced considerably, such that an echocardiogram machine in 1995 was the cost of a house ($250,000), whereas today a very capable portable machine is the cost of a car ($30,000–$60,000). This has allowed provid-ers to increase the number of machines available. However the “silo” mentality between medical specialty craft groups has limited cross- discipline training opportunities.

Australia is a good model for how education can lead a change in practice. The adoption of TEE in cardiac sur-gery in the mid-1990s was relatively slow and ad hoc, with the early adopters going overseas or getting limited training within Australia. There was a deficiency of train-ing courses and even textbooks on TEE. Those wishing to adopt the technology had to work very hard to obtain the knowledge and practice to become proficient. This produced a need for a high- quality and extensive knowl-edge to cater to the diagnostic- level interpretive skills required in cardiac surgery. This led to the production of the University of Melbourne distance education courses. These courses provided access to knowledge for those wishing to become skilled in TEE, with the consequence that many Australian anesthesiology or cardiothoracic surgery depart-ments insisted that cardiac anesthesiologists complete the Postgraduate Diploma or an equivalent fellowship or exam-ination such as the NBE PTEeXAM. This approach was endorsed by the Australian and New Zealand College of Anaesthetists. However, this approach limited the echocar-diography knowledge to cardiac anesthesiologists perform-ing TEE. In response to demand, the TEE- based course split into 2 parts in 2009, with the first half aimed at the noncar-diac anesthesiologist, emergency, and intensive care physi-cians, where TTE would be the first and most frequently used echocardiography modality, complemented by a basic level of TEE. Clinicians can limit their echocardiography training and graduate with a postgraduate certificate or continue to the level of diploma where the focus is TEE and diagnostic- level knowledge. The delivery of these courses is entirely via distance education, which allows clinicians to study in their own time and place, thereby facilitating access to information. In addition, formalized training workshops were established to teach the HEART scan goal- focused study. The impact on clinical practice has been dramatic. In Australia and New Zealand, where there are approximately 5000 anesthesiologists or critical care physicians, 1375 have completed the workshops, more than 400 have completed the certificate level, and more than 500 have completed the diploma level. The predominant use of echocardiography among anesthesiologists and critical care physicians is now goal- focused TTE, with TEE remaining predominantly the domain of the cardiac anesthesiologist (personal commu-nication, University of Melbourne Ultrasound Education Group, 2012). The importance of distance- based education is to make it easy for clinicians to work through a process to acquire the knowledge in a structured and graded manner. These courses are now run as professional development pro-grams for the Society of Cardiovascular Anesthesiologists (SCA ON- CUE levels 1 and 2), increasing availability to North American and worldwide practice.

It is likely that education platforms that are tailored to physician needs and practice environments will facilitate a high rate of adoption of ultrasound into clinical prac-tice. There are already many short courses, workshops, texts, and electronic material to aid learning. A selection of iPhone apps and websites are shown in Table 5, which will aid the practitioner as reference guides, aide- memoires, pocket books, or calculators and report forms as well as platforms for e- learning. However, integration of ultra-sound into everyday practice (ultrasound for everyone) will only be accomplished when it is part of the curricula of medical schools and specialist training organizations. A recent expert panel on intensive care training36 recom-mended unanimously that general critical care ultrasound and basic echocardiography should be a core part of the ICU curriculum. Other societies, boards, and colleges will produce training and practice guidelines to help steer the path of education, practice guidelines, and competency assessment.

IS THERE A DANGER IN WIDESPREAD ADOPTION OF ULTRASOUND?There is certainly widespread consensus from noncardiol-ogy specialties that ultrasound should be an integral part of their practice.19 There is, however, a paucity of outcome data on the use of routine ultrasound in anesthesiology, intensive care, or emergency medicine. As a comparative example, it took 15 to 20 years after widespread adoption of the pulmo-nary artery catheter before research questioned whether the balance was harm or benefit.103,104 Research is likely to direct appropriate use, and better define clinical situations in which benefit clearly outweighs risk of harm. This research, combined with expert consensus leads to recommendations for the performance and appropriate use of echocardiogra-phy.105,106 Education, definition of competency, and quality assurance programs are likely to evolve to reduce the risk of harm. This is a dynamic topic, which is likely to change as we move toward widespread adoption of ultrasound into everyday practice.

SUMMARYUltrasound is becoming an integral part of anesthesiol-ogy and acute care medical practice. What started out as TEE for cardiac surgery has spread to ultrasound- guided regional anesthesia and vascular access, goal- focused TTE, and emerging use of lung, abdominal, vascular, and soft tis-sue imaging. The multiple roles of ultrasound have many complementary components, and the future direction is to consider ultrasound as simply part of clinical assessment and an aid to guide procedures. E

AUTHOR AFFILIATIONSFrom the *Anesthesia and Pain Management Unit, Department of Surgery, The University of Melbourne, Carlton, Victoria, Australia; †Department of Anesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; ‡Department of Anaesthesia and Pain Management, The Royal Hobart Hospital, The Royal Melbourne Hospital, Parkville, Victoria, Australia; §Department of Anaesthesia, Monash Medical Centre, Melbourne, Victoria, Australia; ‖Department of Medicine, The University of Tasmania, Hobart,




Australia; ¶Department of Anaesthesia, Sir Charles Gairdner, Perth, Australia; #Department of Anaesthesia, Joondalup Hospital, Perth, Australia; **Echocardiography Group, Department of Surgery, The University of Melbourne, Carlton, Victoria, Australia; ††Fremantle School of Medicine, University of Notre Dame, Perth, Australia; ‡‡Emergency Department, Frankston Hospital, Peninsula Health, Frankston, Australia; §§Department of Anaesthesia, Royal Perth Hospital, Perth, Australia; and ‖‖Department of Surgery, The University of Melbourne, Carlton, Victoria, Australia.

DISCLOSURESName: Colin F. Royse, MBBS, MD, FANZCA.Contribution: This author helped prepare the manuscript.Conflicts of Interest: Employee of University of Melbourne; involved in the development of course materials described (Postgraduate Certificate and Diploma of Clinical Ultrasound and HEART scan), Director of Heartweb, which conducts the SCA ON- CUE courses.Name: David J. Canty, MBBS, FANZCA, PGDipEcho.Contribution: This author helped prepare the manuscript.Conflicts of Interest: Employee of University of Melbourne; involved in the development of course materials described in the text (Postgraduate Certificate and Diploma of Clinical Ultrasound and HEART scan).Name: John Faris, MBChB, DAvMed, FAFOM, FFOM, FANZCA, BA, ASCeXAM, PGDipClinUs.Contribution: This author helped prepare the manuscript.Conflicts of Interest: Involved in the development of course materials described in the text (Postgraduate Certificate and Diploma of Clinical Ultrasound and HEART scan).Name: Darsim L. Haji, MBChB, FACEM, PGDipEcho.Contribution: This author helped prepare the manuscript.Conflicts of Interest: Involved in the development of course materials described in the text (Postgraduate Certificate and Diploma of Clinical Ultrasound and HEART scan).Name: Michael Veltman, MBBS, FANZCA, ASCExam, FASE.Contribution: This author helped prepare the manuscript.Conflicts of Interest: Involved in the development of course materials described in the text (Postgraduate Certificate and Diploma of Clinical Ultrasound and HEART scan).Name: Alistair Royse, MBBS, MD, FRACS, FCSANZ.Contribution: This author helped prepare the manuscript.Conflicts of Interest: Employee of University of Melbourne; involved in the development of course materials described in the text (Postgraduate Certificate and Diploma of Clinical Ultrasound and HEART scan), Director of Heartweb, which conducts the SCA ON- CUE courses.This manuscript was handled by: Martin J. London, MD.

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