TEE in Non-Cardiac Surgery. Govind Rajan MBBS Professor, Director of Clinical affairs Chief of Surgical Liaison Corp. UCI Health, Irvine, California

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1 TEE in Non-Cardiac Surgery Govind Rajan MBBS Professor, Director of Clinical affairs Chief of Surgical Liaison Corp. UCI Health, Irvine, California

2 Disclaimer MADgic Airway MADgic Wand 2

3 Talking Points.. Problems with non-cardiac surgery case scenarios My thoughts Your thoughts 3

4 A deadly scenario 52year male presents with history of HTN and DM, and Ulcerative colitis refractory to medical management for laparoscopic colectomy Further Stress ECHO, which was negative for ischemia ECHO preoperatively EF of 58%, Mild LVH 4

5 Anesthetic Plan Routine GA with a large bore IV And a little bit about the Laparoscopic Colectomy Head down position Abdominal Insufflation Minimal Blood Loss During the first 30 min. 5

6 Early events in the OR 6

7 Early events in the OR 7

8 Intraoperative TEE 8

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10 Early events in the OR 10

11 Early events in the OR placed arterial line 11

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14 Early events in the OR 14

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17 Early events in the OR 17

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21 Early events in the OR 21

22 Early events in the OR 22

23 Early events in the OR 23

24 Early events in the OR 24

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27 Hyperdynamic post Impala.. 27

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33 Post revascularization 33

34 Rescue TEE during intraoperative hemodynamic instability 34

35 The context for the case scenario.. We have a complicated case and I am covering two rooms with Junior Resident What is the problem with the patient? Well he has extensive cardiac history and is 88 years old. Not a case for the first year resident OK, I will switch and have a senior take over the complicated case.. 35

36 The Case 80-year-old female sustained left femoral neck fracture a year ago s/p Hemiarthroplasty Hemiarthroplasty that subsequently found to be draining pus for about 4 months Now with increasing pain Wheel-chair bound No fever or chills 36

37 The Case Medical History Hypertension Diabetes-Type II Past Surgical History Hemiarthroplasty Medications: ASA, Carvedilol, Lasix, Glypizide, Hydralazine, Metformin, Valsartan Allergies: Penicillin 37

38 The Case Physical Exam BP: 148/72 HR: 76 RR: 14 Tc: 36.0 Ht: cm Wt: 52 kg 38

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40 Physical Exam Alert oriented HEENT: WNL Heart: RRR, No Murmurs Lungs: CTA Abdomen: Soft, Non-tender Extremities: PPP, No Edema

41 Diagnosis and Plan.. Infection of left hip prosthesis Orthopedic surgery --- primary on the case Plan: Medical Consult Cardiology Consult Infectious disease consult Interventional Radiologist consult 41

42 Cardiologists take and Echo findings Moderately decreased left ventricular systolic function: EF is 40% Elevated LA and LVEDP Severely dilated left and right atrium Trace pericardial Effusion Estimated RAP 15 mmhg Estimated RVSP 74.8 mmhg 42

43 Recommendation: Suggested less than 5% risk of perioperative adverse cardiac events with recommendation Judicious fluid management Perioperative B Blockers Preferably regional anesthesia 43

44 Anesthetic Plan: GA Arterial Line She had a PICC line for antibiotic administration So one more bigger sized IV access Surgery scheduled for about 2 hours After induction TEE probe was also inserted Some thing to be aware of among elderly patients undergoing Hip arthroplasty surgery.. Patient specific Surgery specific 44

45 Now the funs begins..

46 Early debris in right heart and IVC 46

47 Early in the case..with surgical manipulation.. The debris from IVC IVC SVC 47

48 Early debris in right heart and IVC 48

49 During cementing without pressurising 49

50 During cementing without pressurising 50

51 The RV strain with dilatation.. 51

52 The RV strain with dilatation.. 52

53 Continued RV insult 53

54 Continued RV insult 54

55 Post Cardiac arrest s/p with CPR in lateral position, epinephrine administered

56 After resuscitation

57 High dose inotropes and temporary occlusion of femoral vein 57

58 Post operative before sending the patient to ICU

59 Liver Transplant and TEE A 55 year old man with History of Hep C and Hepatoma for liver transplant. Otherwise healthy Great exercise tolerance Anesthesia and surgery progresses uneventfully Inductions and lines Pre-Hepatic and intrahepatic 59

60 PE during Liver Transplant.. 20 min in to reperfusion.. 60

61 PE during Liver Transplant.. 61

62 PE continued.. 62

63 PE continued.. 63

64 PE during LTx 64

65 PE during LTx 65

66 PE during Liver Transplant.. 66

67 67 Post PE resolution hyper-dynamic myocardium..

68 Anesthetic Considerations and Intraoperative Management Recommendations COR LOE The emergency use of perioperative TEE is reasonable in patients with hemodynamic instability undergoing noncardiac surgery to determine the cause of hemodynamic instability when it persists despite attempted corrective therapy, if expertise is readily available. IIa C The routine use of intraoperative TEE during noncardiac surgery to screen for cardiac abnormalities or to monitor for myocardial ischemia is not recommended in patients without risk factors or procedural risks for significant hemodynamic, pulmonary, or neurologic compromise. III: No Benefit C 68

69 Indications for intraoperative TEE for non Cardiac Surgery Liver Transplant Impending PE Cement Embolism Syndrme Impending temponade Pacemaker or ICD lead extraction And many other situations that continue to reported 69

70 Your take