Download Transthoracic echocardiography in the perioperative setting

REVIEW
URRENT
C
OPINION
Transthoracic echocardiography in the
perioperative setting
Martin Ruben Skou Jørgensen a, Peter Juhl-Olsen a
Christian Alcaraz Frederiksen b, and Erik Sloth a
Purpose of review
A need for further assessment of patients in the perioperative setting and an increasing availability of
ultrasonography equipment have facilitated the diffusion of ultrasonography and lately focused
transthoracic echocardiography (TTE) in anesthesiology practice. This review will discuss the possible use
of focused TTE in the perioperative setting and provides an update on present and future perspectives.
Recent findings
Several studies focusing on patient management and diagnostic accuracy of perioperative, focused TTE,
have been published recently. Several multidisciplinary guidelines addressing use and educational aspects
of focused ultrasonography are available, yet guidelines focusing solely on the use in the perioperative
setting are lacking.
Summary
Hemodynamically significant cardiac disease or pathophysiology can be disclosed using TTE. Focused
TTE is feasible for perioperative patient management and monitoring and will be an inevitable and
indispensable tool for the anesthetist. Future research should focus on the outcome of perioperative TTE
performed by anesthetists, using rigorous study designs and patient-centered outcomes such as mortality
and morbidity.
Keywords
anesthesia, cardiac physiology, hemodynamic determinants, pathophysiology, perioperative setting,
transthoracic echocardiography
INTRODUCTION
Maintaining sufficient tissue oxygenation is a key
issue for the anesthesiologist in the perioperative
period. To ensure this, hemodynamic monitoring
tools are applied, including continuous electrocardiogram, systemic and central venous blood
pressure, arterial blood samples, central venous
oxygenation and cardiac output. However, standard
hemodynamic monitoring provides markers of
overall circulatory status, but adds little in terms
of the underlying physiology [1–3]. The determinants of cardiovascular physiology; preload, afterload, contractility, diastolic function and heart rate
can be thoroughly evaluated, in addition to disclosing obvious cardiac disease by cardiac ultrasonography.
Transesophageal echocardiography (TEE) has
been used by cardiac anesthesiologists for more than
35 years. It is recognized as a pivotal monitoring tool
to guide surgical and anesthetic decision-making
[4,5]. However, TEE exposes the patient to some risk
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and has limited value after extubation. To overcome
these limitations, we introduced focused transthoracic cardiopulmonary ultrasonography in anesthesia
and critical care in the late 1980s [6]. The ‘surface
approach’ [7] allows cardiac visualization throughout the entire perioperative period, including
the preoperative anesthetic evaluation, intraoperative hemodynamic guidance and postoperative
assessment of cardiopulmonary status [5,8 ,9–13,
14 ,15–19].
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a
Department of Anesthesiology and Intensive Care Medicine and
Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
b
Correspondence to Erik Sloth, MD, PhD, DMSc Professor of Point-OfCare Ultrasound Consultant Cardiothoracic Anaesthetist, Department of
Anaesthesiology and Intensive Care Medicine, Aarhus University
Hospital, Palle Juul-Jensens Blv. 99, 8200 Aarhus, Denmark.
Tel: +45 4075 7844; e-mail: [email protected]
Curr Opin Anesthesiol 2016, 29:46–54
DOI:10.1097/ACO.0000000000000271
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Transthoracic echocardiography Jørgensen et al.
KEY POINTS
! Focused TTE is rapid, repeatable and noninvasive.
! Focused TTE reveals unexpected cardiac disease and
pleural scanning reveals additional unexpected disease
of hemodynamic importance.
! Full disclosure of hemodynamic status requires
assessment of preload, afterload and systolic and
diastolic function.
! Focused cardiac ultrasonography alters perioperative
management and may have predictive value.
! We recommend an expertise pyramid in order to
optimize education and structuring daily practice.
INDICATIONS, ULTRASONOGRAPHIC
IMAGING AND FOCUSED PROTOCOL
APPROACH
Indications
Indications for a preanesthetic-focused TTE have
been suggested to include systolic murmurs, potential valve disease, hemodynamic instability, assessment of ventricular function, unexplained dyspnea,
hypoxemia or limited functional capacity [29]. The
Society of Critical Care Anesthesiologists has recently presented recommendations for standard clinical
indications, learning goals and competencies regarding focused ultrasonography use within anesthesiology-critical care medicine [28 ].
&&
Imaging and scanning terminology
The growing enthusiasm regarding transthoracic echocardiography (TTE) for noncardiologists
has led to several focused scanning protocols
for cardiopulmonary optimization. Protocols,
named by acronyms, include Focused Assessed
Transthoracic Echocardiography (FATE) [6], FEEL
[20], H.A.R.T. [21], CLUE [22], FUSE and RUSH
[23]. They all share the same key features being
problem-oriented, attempting to answer simple
dichotomous questions, limited in time consumption, easily repeatable and without a need for transporting the patient. Implementation has been
facilitated by technological progress resulting
in enhanced image quality, high portability and
lower equipment costs.
Thus, after a period in which focused TTE by
noncardiologists has met criticism and concern, it
has disseminated into anesthesia, critical care and
emergency medicine because of a self-explanatory
clinical need. Moreover, clinical studies and perioperative case series report that focused TTE prevents
adverse events and has direct clinical impact [5,9–
13,14 ,15–18,24,25]. Acknowledging the accumulating evidence, several leading academic societies
now promote and recommend focused TTE as a
mandatory tool for all physicians sufficiently
trained to improve patient care [26 ,27 ,28 ].
The introduction of a new, advanced and
observer-dependent technique constitutes an educational challenge to the anesthesiology community. International consensus has to be obtained on
levels of education and criteria for certification.
This review will briefly discuss this issue, and will
also explain how cardiac ultrasonography is used to
quantify the key determinants of cardiovascular
function. Additionally, this review will provide an
overview of the literature on focused TTE in the
perioperative period.
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A focused TTE protocol for the perioperative setting
should include a sufficient set of views to assess the
key determinants of cardiovascular function. We
recommend the FATE protocol, as it is among the
most comprehensive focused transthoracic protocols allowing basic TTE (qualitative assessment
and pattern recognition) as well as more advanced
Doppler measurements if performed by skilled practitioners. Furthermore, pleural scanning is part of
the protocol (Fig. 1).
Subcostal four-chamber view
The transducer is placed close to the midline and
just beneath the thoracic curvature. The probe
orientation marker points to the patient’s left and
the imagine plane is directed toward the left
shoulder.
Apical four-chamber view
The transducer is placed above the apex of the heart.
The orientation marker points to the patients left,
and the imagine plane is aligned with the axis of
the heart.
Parasternal long-axis and short-axis
The transducer is placed just left to the sternum, on a
line between the apex of the heart and the middle
of the patient’s right clavicle. The long-axis will
appear when pointing the orientation marker
toward the patient’s right shoulder, and short-axis
with 90 degrees clockwise rotation.
Pleural scanning
The transducer is placed on the posterior axillary
line. Identification of the diaphragm facilitates separation of the thoracic and abdominal contents and
potential pleural fluid will accumulate just cranially
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Cardiovascular anesthesia
Focus assessed transthoracic echo (FATE)
Focus assessed transthoracic echo (FATE)
Scanning though position 1-4 in the most favourable sequence
Bisic FATE views
Polnt cranlal
Polnt right
Polnt right
(patlent’s left) (patlent’s
left back)
RA
RA
RV
LV
Extended FATE views
0º
LIVER
LV
Post 1: Subcostal 4-chamber
LV
IVC
RA LA
LA
RA
LV
Post 2: Apical 4-chamber
Post 1: Subcostal vena cava
Polnt left
(patlent’s right
shoulder)
Polnt right
(patlent’s left
shoulder)
RV
AO
LV
RA
Post 2: Apical 2-Chamber
0º
Polnt right
(patlent’s
back)
LV
RV
LV
LA
LA
Post 3: Parasternal long axis Post 3: Parasternal LV short axis
Dlaphragm
Lung
1
4
Polnt right
(patlent’s left
shoulder)
RV
3
2
AO
Post 2: Apical long-axis
Left
Right
Polnt cranlal
Liver/spleen
LA
RA
120º
Polnt right
(patlent’s right
shoulder)
60º
Polnt right
(patlent’s left
shoulder)
A1
A2
P1
A3
P2
P3
LA
AO
Post 2: Apical 5-Chamber
Polnt right
(patlent’s left
shoulder)
RA
RV
R
NC L PA
LA
4
Pos 4: Pleural scanning
Pos 3: Parasternal short axis mitral plane Pos 3: Parasternal aorta short axis
FIGURE 1. Focus assessed transthoracic echocardiography (FATE) protocol. Basic and extended views. AO, aorta; IVC,
inferior vena cava; LA, left atrium; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RV, right ventricle.
to the diaphragm. Atelectasis of the lung can also
be disclosed.
Subcostal vena cava view (extended view): is
sought from the subcostal view by rotating the
probe and hence the ultrasound image around the
inferior vena cava’s entry into the right atrium.
Apical two-chamber and long-axis view
(extended views): these views are achieved from
the apical four-chamber view by rotating the transducer.
Apical five-chamber view (extended view): the
view is obtained from the apical four-chamber view
by tilting the transducer and thus presenting a more
anterior scanning plane.
Parasternal short-axis at mitral plane and aortic
valve level (extended views): these views are
achieved from the regular short-axis view by moving
the scanning plane along the axis of the heart.
Focused transthoracic echocardiography
protocol in daily clinical practice
To perform a focused TTE, the examiner must, as a
minimum, be able to obtain the basic views and
recognize the most significant cardiopulmonary
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disease. Most hemodynamic significant disease
and pathophysiology can be detected by basic
two-dimensional (2D) echocardiography.
A focused protocol warrants a stepwise approach
including obvious disease, assessment of wall thickness and chamber dimensions, assessment of biventricular function and visualization of pleura [9].
Preferably, patients should be examined at the
point-of-care with portable equipment and examination should be repeated in the case of deterioration, allowing for immediate interpretation, by the
performing hemodynamic specialist, in relation to
the clinical context.
In the perioperative setting, wherein time is of
the essence, TTE should be performed rapidly.
Focused protocols have demonstrated an ability to
ensure adequate images to assess hemodynamic
status. This is possible despite frequent, limited
acoustic windows, tachypnea and challenging
patient positioning [5,6,9,17]. If one view is difficult, the examiner should move on to the next.
Changes in patient positioning and respiration will
often optimize image quality [9]. The sequence of
the views should reflect suspected positive findings;
in some cases, one view may be adequate.
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Transthoracic echocardiography Jørgensen et al.
It should be emphasized that a focused protocol
does not replace a comprehensive TTE performed by
a cardiologist [30 ]; referral criteria for a comprehensive TTE need to be respected [28 ,31 ] and
consultation by a cardiologist should be considered.
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&&
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FOCUSED TRANSTHORACIC
ECHOCARDIOGRAPHY FOR
HEMODYNAMIC ASSESSMENT AND
OPTIMIZATION
The following addresses the importance of 2D imaging and highlights the need for knowledge about
cardiac dimensions, hemodynamic optimization
based on basic physiological determinants and
hence why focused TTE is superior to any other
monitoring techniques.
Preload
Preload refers to the end diastolic volume of a ventricle and is a surrogate measure of sarcomere
length. Perioperatively, preload can be estimated
using simple one-dimensional, two-dimensional,
or three-dimensional quantification of the left ventricular end-diastolic volume. As the left ventricular
volume is prone to intersubject variation, this
method is predominantly recommended for
within-subject changes [32]. In extreme conditions,
severely impaired ventricular filling can be visualized as ‘kissing walls’ when the papillary muscles
touch each other at end-systole corresponding to
full emptying of the ventricle (parasternal short-axis
(a)
V
5
view). Conversely, a high left ventricular filling
pressure will facilitate a fixed bulging of the
interatrial septum into the right atrium [33].
In addition, the respiratory changes of the
inferior vena cava (Fig. 2) can be used to predict
volume responsiveness during positive pressure
ventilation [34,35]. A variation above 12–18%
exhibited high sensitivity and specificity; this finding has, however, later been questioned [36].
Afterload
Afterload is an elusive concept often defined as the
force against which the ventricle contracts. It may
be expressed as wall stress and is, by the law of
LaPlace, proportional to ventricular radius and ventricular transmural pressure, but inversely proportional to myocardial thickness. At the same
systolic blood pressure, a hypertrophic ventricle
with a small cavity will have a low afterload, whereas
a dilated and thin-walled ventricle is subject to a
high afterload [37]. The development of aortic valve
stenosis implies a concomitant increased left ventricular pressure work ensuring an adaptive decrease
in afterload (left ventricular hypertrophy and
reduced left ventricular cavity). Progress in aortic
stenosis will finally result in an increase in left
ventricular afterload (thinning of the left ventricular
myocardium and dilatation of the left ventricular
cavity) when the left ventricular pressure work
requirements exceed the capacity of the left ventricular myocardium.
(b)
V
5
10
10
15
15
–2
–3
–2
–1
50 mm
FIGURE 2. Examples of hemodynamic assessment by focused echocardiography. Two-dimensional and M-mode scans of the
inferior vena cava. (a) Total collapse of the inferior vena cava caused by hemorrhagic shock. (b) Distended inferior vena
cava, in this case caused by volume overload. Note the absence of caliber change during the respiratory cycle. White arrow,
inferior vena cava; Black arrow, peak inspiration.
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Cardiovascular anesthesia
Ventricular contractility
Ejection fraction remains the most common echocardiographic expression of left ventricular systolic
function, although it may be affected by changes in
both preload and afterload. Echocardiography most
of the time relies on eyeballing for the estimation of
ejection fraction. Eyeballing correlates well with
quantitative techniques and allows us to categorize
ejection fraction in subgroups [38,39]: more than
52%; normal, 41–52%; mildly abnormal, 30–40%;
moderately abnormal and less than 30%; severely
abnormal [40 ]. Eyeballing of ejection fraction may
be performed from the apical four-chamber and
parasternal views. To minimize the effect of
regional dyskinesia, we recommend using more
than one view for assessment of ejection fraction.
Intraoperatively, patient positioning and the surgical field often limit accessibility to the parasternal
views.
If impaired image quality prevents precise endocardial border definition, semiquantitative methods
can be applied. For example, ejection fraction can be
approximated by use of the mitral annular plane
systolic excursion (MAPSE). MAPSE is a reflection of
left ventricular longitudinal contractility and is
simply measured as the systolic excursion of the
mitral valve annuli [41,42 ,43]. MAPSE must be
measured in the apical four-chamber view. If only
the parasternal views are available, the mitral-septal
separation may be used. A separation of less than
7 mm between the anterior mitral valve leaflet and
the interventricular septum, in early diastole, is
indicative of normal ejection fraction [44].
Tricuspid annular plane systolic excursion is a
well-validated marker of right ventricular systolic
function [45]. Because of its complex geometry, the
right ventricle cannot be visualized sufficiently in
2D views precluding the quantification of volume
changes. Thus, excursion distance can be measured
at the lateral tricuspid valve annulus in the apical
four-chamber view. Dilatation of the right ventricle,
defined as a basal diameter more than 41 mm in the
apical four-chamber or more than 30 mm in the
parasternal long axis view [40 ], is a sign of either
right-sided heart failure or pressure or volume overload [46]; this should prompt further investigation
prior to positive pressure ventilation.
stenosis [47,48], where diastolic dysfunction is often
present, suggests a considerable impact. In cardiac
ultrasonography, the presence of left ventricular
hypertrophy in combination with left atrial enlargement is highly predictive of diastolic dysfunction
[49,50]. Advanced methods for quantitative assessment of diastolic function have been developed and
include pulsed wave and tissue Doppler imaging.
However, the intraoperative validity of these indices
has been disputed [51].
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Diastolic function
Left ventricular diastolic function depends on passive ventricular compliance and active relaxation
properties susceptible to ischemia. The significance
of diastolic dysfunction on intraoperative hemodynamic stability has not been described, but the 5–7
fold risk of perioperative death seen with aortic
50
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Heart valve disease
Unexpected valve disease has major influence on
patient outcome [47,48], but is easily missed during
clinical examination [52].
In aortic stenosis, the aortic leaflets appear
thickened, hyperechoic because of calcification
and restricted in motion. The aortic valve can be
visualized in parasternal long-axis/short-axis, apical
five-chamber and apical long-axis views. Quantitatively, significant aortic stenosis is defined as a maximum flow velocity across the valve of at least 3 m/s
using continuous wave Doppler (Fig. 3) [53,54 ]. We
emphasize that flow velocity across the valve is
proportional to stroke volume; in patients with
tachycardia or low cardiac output, severity of aortic
valve stenosis may be underestimated [28 ].
The presence or absence of mitral valve insufficiency may be assessed with color Doppler. Whereas
insufficiency jets are easily visualized, actual quantification of mitral regurgitation is complex and often
precluded by jet eccentricity. Mitral valve stenosis
may be seen as thickened, hyperechoic leaflets and
restricted leaflet motion. Severity can be assessed
quantitatively by using continuous wave Doppler to
measure the diastolic transmitral pressure drop
[53,28 ].
&
&&
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Pericardial effusion
Pericardial effusion is easy to visualize (Fig. 4) [55].
Depending on the size and pace of accumulation, it
may compromise circulation and in severe cases
cause cardiac tamponade. An effusion with an echocardiographic systolic or diastolic free-space of
less than 10 mm is considered insignificant [56].
However, the presence of tamponade is a clinical
diagnosis, as chamber compression by the pericardial effusion may not be visible in available scan
planes [57].
Pleural effusion
Case reports of large pleural effusions causing tamponade-like pathophysiology have been published
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Transthoracic echocardiography Jørgensen et al.
V
5
5.20 m/s
1 AV max
AV maxPG 108.15 mmHg
10
15
[m/s]
–1
–2
–3
–4
–5
–6
–4
–3
50 mm –0
–1
–2
52
HR
FIGURE 3. Maximum flow velocity across the aortic valve using continuous wave Doppler. Note a velocity more than 3 m/s
and hence a significant valve stenosis. Further quantification showed a pressure gradient of 108 mmHg. White þ, maximum
transaortic velocity (AV Vmax) of 5.20 m/s.
CLINICAL STUDIES AND RESEARCH
PERSPECTIVES
[29,58–60] supported by recent studies [61,62].
Note that the positioning of the patient is relevant
and pleural effusion is easier to locate when the
patient is placed in the anti-Trendelenburg position
(Fig. 5).
(a)
During the last decade, only a few studies concerning the perioperative use of focused TTE in anesthesiology have been published. These studies are
(b)
V
V
5
5
10
RV
LV
LV
RV
15
15
RA
LA
V
(c)
V
(d)
PE
RV
5
5
PE
10
LA
RA
LVM
LV
LVM
10
LVM
LV
15
PE
FIGURE 4. Examples of disease of perioperative significance disclosed by focused echocardiography. (a) Dilated left
ventricle, as seen in left ventricle failure. (b) Dilated right ventricle with enlarged right atrium. Typical finding if right side
pressure increases, for example pulmonary embolus. (c) Pericardial effusion causing reduced left ventricular filling. The
myocardium appears hypertrophic, as the left ventricle end-diastolic diameter is less than 1.5 cm. (d) Hypertrophic left
ventricular myocardium. End-diastolic diameter is approximately 3.5 cm. LA, left atrium; LV, left ventricle; LVM, left ventricular
myocardium; PE, pericardial effusion; RA, right atrium; RV, right ventricle.
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Cardiovascular anesthesia
PL
V
AL
DI
PL
LI 15
FIGURE 5. Typical pleural effusion with concomitant
atelectasis. AL, atelectasis; DI, diaphragm; LI, liver; PL,
pleural effusion.
heterogeneous in study design and patient characteristics. The most interesting recent findings are
highlighted below.
In recent years, perioperative case reports have
indicated a requirement for additional preanesthetic evaluation and monitoring [9,15,18,63]. Perioperative studies addressing the clinical impact
of focused TTE demonstrate alterations in perioperative management and a predictive capability
of perioperative adverse cardiac events [5,10–
12,17,24]. Alterations in anesthetic management
constitute preoperative optimization (e.g. pleural
drainage), supportive preoperative and intraoperative hemodynamic optimization such as volume
infusion and use of vasoactive/cardioactive drugs,
step-up or step-down in level of monitoring, change
in anesthetic technique, change in surgical procedure, postponement of surgery, change in postoperative care or even cancelation.
Recently, Kratz et al. [14 ] found focused TTE to
be applicable in 91% of intraoperative cases. They
discovered cardiopulmonary abnormalities in 95%
of unstable patients and in 30% of stable patients
[64].
In a prospective study by Bøtker et al. [8 ] on
patients undergoing urgent surgical procedures, the
FATE – protocol proved feasible. Unexpected disease
was revealed in 27% of cases, leading to changes in
anesthesia techniques or supportive actions in 43%
of cases. Unexpected disease was only encountered
in a patient subpopulation above 60 years and/or
American Society of Anesthesiologists score of at
least 2. It was suggested that focused TTE has a
clinical impact in elderly people with physical
limitations.
Cowie [24] retrospectively reviewed a group of
222 patients preoperatively evaluated with focused
TTE to assess the predictive value of cardiac disease.
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Adverse events occurred in patients with pulmonary
hypertension, ventricular dysfunction and stenotic
valve disease. In contrast, no patients with a normal
preoperative cardiac ultrasonography experienced
adverse events.
Canty et al. [10] studied elective patients preoperatively and emergency noncardiac surgery
patients and showed a step-up in treatment in 20
and 36% of patients, respectively, and equally interesting a step-down in 34 and 8%, respectively. The
step-down consequences included no cardiology
referral, no invasive monitoring and no cancelation
of surgery [11].
Randomized-controlled trials with mortality or
morbidity end-points of focused TTE protocols in
the perioperative setting are still lacking and should
be a focus of attention in the future.
EDUCATION
Within acute care specialties – emergency medicine
and critical care medicine, various academic
societies have published guidelines on education
[26 ,28 ,65,66]. World Interactive Network
Focused On Critical Ultrasound (WINFOCUS)
recently published international recommendations
including education, certification and accreditation
of training programs. These are endorsed by various
academic societies [26 ].
Still, no recommendations focusing solely on
perioperative TTE, performed by noncardiac anesthetists, have been published.
We believe that a pyramid structure could be
feasible in anesthetic practice and training. A pyramid consisting of a broad-based bottom representing the majority of physicians, performing at a basic
level, and on top an expert minority. In between
these two levels, physicians would gradually acquire
knowledge and skills. A pyramid structure would
lead to efficient use of staff resources. Expertise
could be assigned according to case complexity
and the minority with a higher skill-level could
supervise and teach the less skilled majority of staff.
Studies addressing training and achievement of
technical skills in focused TTE indicate [20,28 ,67–
69] that only limited intervention is needed to
obtain basic adequate images suitable for interpretation. Cardiac ultrasonography simulation and
supervised scans of patients seem to be efficient
learning methods [26 ,70].
Background knowledge and disease recognition
can be taught using interactive e-learning before or
after focused practical hands-on training [71]. This is
supported by the WINFOCUS organization [26 ]
endorsing a mixture of e-learning and formal faceto-face didactics to acquire background knowledge
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Transthoracic echocardiography Jørgensen et al.
and training in image acquisition and interpretation
through supervised examinations.
To ensure sufficiently trained staff in the future,
education should start at an early level. In some
countries, anesthesiology trainees receive formal
basic-level training, and studies suggest that a
focused perioperative bedside ultrasonography curriculum is feasible [72,73,74 ]. Furthermore, studies
regarding teaching of ultrasonography at the pregraduate level have been published [75–77].
&
CONCLUSION
Focused perioperative TTE is feasible preoperatively,
intraoperatively and postoperatively. Focused protocols should be incorporated in the daily clinical
patient evaluation and documented according to
existing terminology. Focused TTE reveals real-time
hemodynamics and physiological determinants, it
holds immediate diagnostic capability, a possible
predictive capability has been suggested and it facilitates clinical perioperative decision-making.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
E.S. has given lectures for Sonosite, GE, and BK-medical
and is co-owner of usabcd ltd. offering e-learning and
hands-on courses in ultrasonography.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
&
of special interest
&& of outstanding interest
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