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 Table of Contents  
CLINICAL OBSERVATION
Year : 2017  |  Volume : 130  |  Issue : 23  |  Page : 2887-2888

Analysis of 1-year Consecutive Application with Focused Transthoracic Echocardiography in Noncardiac Surgery


Department of Anesthesiology, The Affiliated Drum Tower Hospital of Nanjing University School of Medicine, Nanjing, Jiangsu 210008, China

Date of Submission13-Sep-2017
Date of Web Publication24-Nov-2017

Correspondence Address:
Zheng-Liang Ma
Department of Anesthesiology, The Affiliated Drum Tower Hospital of Nanjing University School of Medicine, Nanjing, Jiangsu 210008
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0366-6999.219144

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Keywords: Echocardiography; Hypotension; Intraoperative Complication; Noncardiac; Surgery; Transthoracic


How to cite this article:
Li BB, Cui XL, Zhang Y, Zhang J, Ma ZL. Analysis of 1-year Consecutive Application with Focused Transthoracic Echocardiography in Noncardiac Surgery. Chin Med J 2017;130:2887-8

How to cite this URL:
Li BB, Cui XL, Zhang Y, Zhang J, Ma ZL. Analysis of 1-year Consecutive Application with Focused Transthoracic Echocardiography in Noncardiac Surgery. Chin Med J [serial online] 2017 [cited 2017 Dec 12];130:2887-8. Available from: http://www.cmj.org/text.asp?2017/130/23/2887/219144



Point-of-care transthoracic echocardiography (TTE) is an evolving field in anesthesia field and verified to have the potential to provide rapid diagnostic information during the hemodynamic collapse in operating room.[1] In this retrospective observatory study, we retrieved all the data of 1-year consecutive use of intraoperative echocardiography in patients with circulatory collapse or undergoing selective high-risk noncardiac surgery.

There were 17 out of over 30,000 surgical cases receiving echocardiographic examinations in our department from May 2016 to May 2017. Preoperative TTE screening was performed in nine cases on the day of surgery, which yielded three cancellations of surgery due to the new findings including unilateral massive pleural effusion, severely depressed left ventricular (LV) contractility (ejection fraction <20%), or cancer embolus in inferior vena cava (IVC) cephalad migrating to second portal of liver. One patient was preoperatively diagnosed with hypertrophied obstructive cardiomyopathy with dynamic LV outflow tract (LVOT) obstruction. However, our examination demonstrated the maximal pressure gradient across LVOT of 25 mmHg (1 mmHg = 0.133 kPa) following Valsalva maneuver. The patient received the mastectomy surgery uneventfully with judicious titration of LV volume and contractility [Supplementary Table 1] [Additional file 1]. Eight transthoracic echocardiographic examinations were performed in the emergency with seven cases intraoperatively and one case in Intensive Care Unit (ICU) ward postoperatively owing to severe hypoxia [Supplementary Table 1], from patient 10 to patient 17]. The leading causes associated with intraoperative cardiovascular collapse were cardiogenic shock including global or regional LV contractility depression, vasoplegia, followed by hypovolemic shock and flash pulmonary edema complicated with severe mitral valve stenosis and atrial fibrillation with rapid ventricular rhythm. All the patients got full recovery from illness and discharged from hospital except one died of malignant ventricular arrhythmia immediately after transferring into ICU. No neurologic lesion was reported in 16 patients after 1-month follow-up.

High-risk patients received preoperative superficial thoracic ultrasound screening, which led to three cancellations of surgery comprising of an unplanned surgical intervention and four significant alterations in anesthetic induction approaches or hemodynamic management. We found that focused TTE performed in the operation room feasible and frequently altered anesthetic management. Notably, this study reiterates the significance that anesthesiologist-operational focused echocardiographic examination elicited a beneficial effect on seeking the clue of severe hypotension and guiding the management for patients with circulatory collapse. First, it can promptly exclude the apparent etiologies leading to circulatory collapse. Two elderly patients suffered the circulatory collapse in total knee/hip replacement surgery, and pulmonary embolism would be an immediately obvious cause to spring to mind in the situation. However, TTE did not identify any thrombi travel in the right heart, pulmonary truck but also could not find any evidence supporting right ventricle strain. Second, point-of-care TTE is a useful modality to identify the ventricle contractility or intracardiac anatomic aberrancy in valve or pericardium with two-dimensional or color modality. Third, IVC collapsibility in patients under mechanic ventilation is a relatively more reliable predictive indicator for fluid responsiveness than static pressure-based variables.[2] However, high IVC collapsibility cannot differentiate hypovolemic shock from distributive shock. Blanco advocated the addition of ultrasound calculation of stroke volume or surrogates to the rapid ultrasound assessment for shock (RUSH protocol) and provided the support for its utility in the differential diagnosis of these two distinct categories of shock.[3] In this study, hemodynamic evaluation with velocity time integral (VTI) of LVOT blood flow was helpful in determining the types of shock [Supplementary Figure 1] [Additional file 2]. The patients within or above the normal range of VTI (18–22 cm) concomitant with high collapsibility of IVC can be ascribed to the vasoplegic syndrome requiring high dose of vasoconstrictor to maintain the blood pressure, whereas those below normal VTI are definitive diagnosis of hypovolemic shock and responsive to fluid loading. Albeit TEE is proven to be effective in rapid assessment during intraoperative hemodynamic compromise in the multitude of studies, it is minimally invasive and not without risk, with recent data suggesting a 1:1000 incidence of gastroesophageal injury and a 1:5000 incidence of death.[4] By contrast, TTE is relatively noninvasive, takes less time to conduct the examination and indicated for awake patients.

Despite clearly altering patient management using point-of-care TTE, it is unclear whether these changes actually influenced and improved the patient outcome compared with empiric treatment since we unexceptionally conducted rapid ultrasound assessment protocol for patients in the crisis with the wide use of ultrasound machine in our department.[5] Notably, all the patients in the present study got full recovery from illness and discharged from hospital except one died of malignant ventricular arrhythmia immediately after transferring into ICU. No neurologic lesion was reported in 16 patients after 1-month follow-up. It might be highly related to accurate diagnosis and prompt intervention under the guidance of ultrasound examination. Therefore, our practice in this field implicated that point-of-care TTE accompanied with quantitative analysis of VTI of LVOT provided invaluable information and real-time images of cardiac structure to interpret the pathophysiological alteration associated with those critical events.

Acknowledgment

We would like to thank Professor Peng for his unselfishness and generous help in manuscript editing.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s)/patient's guardians has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients/patient's guardians understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Supplementary information is linked to the online version of the paper on the Chinese Medical Journal website.

Financial support and sponsorship

This study was supported by grants from the Bureau of Science and Technology of Nanjing Municipal Government (No. 201503019), the Medical Science and Technique Development Foundation of Nanjing Municipal Government (No. QRX17013), and the Project of Key Medical Discipline of Jiangsu Province for 13th 5-Year Plan Development.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jasudavisius A, Arellano R, Martin J, McConnell B, Bainbridge D. A systematic review of transthoracic and transesophageal echocardiography in non-cardiac surgery: Implications for point-of-care ultrasound education in the operating room. Can J Anaesth 2016;63:480-7. doi: 10.1007/s12630-015-0524-7.  Back to cited text no. 1
    
2.
Long E, Oakley E, Duke T, Babl FE, Paediatric Research in Emergency Departments International Collaborative (PREDICT). Does respiratory variation in inferior vena cava diameter predict fluid responsiveness: A Systematic review and meta-analysis. Shock 2017;47:550-9. doi: 10.1097/SHK.0000000000000801.  Back to cited text no. 2
    
3.
Blanco P, Aguiar FM, Blaivas M. Rapid ultrasound in shock (RUSH) velocity-time integral: A Proposal to expand the RUSH protocol. J Ultrasound Med 2015;34:1691-700. doi: 10.7863/ultra.15.14.08059.  Back to cited text no. 3
[PUBMED]    
4.
Piercy M, McNicol L, Dinh DT, Story DA, Smith JA. Major complications related to the use of transesophageal echocardiography in cardiac surgery. J Cardiothorac Vasc Anesth 2009;23:62-5. doi: 10.1053/j.jvca.2008.09.014.  Back to cited text no. 4
[PUBMED]    
5.
Cowie B. Three years' experience of focused cardiovascular ultrasound in the peri_operative period. Anaesthesia 2011;66:268-73. doi: 10.1111/j.1365_2044.2011.06622.x.  Back to cited text no. 5
[PUBMED]    




 

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