Learning Objectives. Denver Health Medical Center. Nothing to Disclose... Advanced Topics in Anesthesia

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1 Nothing to Disclose... Learning Objectives 1. Describe which clinical situations are appropriate for TEE monitoring in noncardiac surgery including indications / contraindications for TEE placement. 2. Demonstrate the key diagnostic TEE views needed for quick assessment of an unstable patient. 3. Utilize basic TEE imaging to diagnose and differentiate hypovolemia, myocardial ischemia, heart failure, pericardial / pleural effusions from normal function. 4. Describe the process of certification in Basic TEE for noncardiac surgery. Denver Health Medical Center Advanced Topics in Anesthesia Physics, Monitoring, and Anesthesia Delivery Devices 3) Principles of Doppler Ultrasound Monitoring Methods 2) Heart Function: Heart Tones, Electrocardiogram (ECG), Echocardiography, Doppler, Cardiac Output instrumentation 2)Echocardiography: Technical Aspects, Complication Cardiovascular System: 1)Echocardiographic Heart Anatomy: Chambers, Valves, Great Vessels, Pericardium, Basic Transesophageal Echocardiography (TEE) ViewsPerioperative Diagnosis and Treatment of Ischemia; ECG, TEE Ischemic HD c) Diagnosis of Myocardial Infarction and Acute Coronary Syndrome; Clinical, ECG, Enzymes, Echocardiography, Nuclear Techniques, Valvular Heart Disease b) Diagnosis (Including Echocardiography), Natural History, Surgical Management Cardiac Tamponade and Constrictive Pericarditis b)diagnosis; TEE, PA Catheter Pulmonary Embolism b)diagnosis, TEE Findings Cardiovascular System TEE ischemic heart disease, valve function, emboli detection, congenital heart disease, pericardial fluid/tamponade, ventricular function and preload assessment (1)

2 CA1/CA2/CA3 Anesthesiology Resident Trauma Anesthesia Rotation»»» American College of Cardiology and American Society of Echocardiography)» Indications for TEE ASA Members and Consultants Strongly Agree Unexplained persistent hypotension Life-threatening hypotension anticipated Agree Known or suspected CV pathology - hemodynamic, pulmonary, or neurological compromise Persistent unexplained hypoxia Equivocal Lung transplantation or major abdominal or thoracic trauma

3 Disagree Esophageal varices Postradiation therapy Hiatal hernia Dysphagia Tracheoesophageal fistul Esophageal trauma Esophageal varices Postradiation therapy Hiatal hernia Dysphagia Tracheoesophageal fistula Esophageal trauma Esophageal varices Postradiation Hiatal hernia Dysphagia Tracheoesophageal fistula Esophageal trauma Esophageal varices Postradiation therapy Hiatal hernia Dysphagia Tracheoesophageal fistula Esophageal trauma

4 Esophageal varices Postradiation therapy Hiatal hernia Dysphagia Tracheoesophageal fistul Esophageal trauma Esophageal varices Postradiation therapy Hiatal hernia Dysphagia Tracheoesophageal fistu Esophageal trauma Esophageal varices Postradiation therapy Hiatal hernia Dysphagia Tracheoesophageal fistula Esophageal trauma

5 Mollod and Felner: Catoire et al: High Low (18) (19) Richens et al: (20) (21) Memtsoudis and Rosenberger et al: (22) (21)

6 TEE rteg TEE Patients Right Patients Left

7 Inferior/ Posterior Superior/ Anterior

8 Lateral / Apical Akinesis Septal / Inferior Hypokinesis Inferior / Apical Akinesis

9 Inferior / Lateral Akinesis Pulmonary Embolism Hypovolemia Atheroscerosis Ascending Aortic Dissection Pericardial Effusion

10 Pericardial Effusion Left Pleural Effusion Right Pleural Effusion Certification

11 (23)»»

12 Letter from the hospital or appropriate department Training Director 150 Total Echo s Performed» At least 50 performed live and reviewed» The National Board of Echocardiography and the ASA Initial projections included an estimate of 300 examinees per year Only an average of 141 examinees per year have taken the exam Average pass rate of 87% over the past three years Moore TJ, Walsh CS, Cohen MR. Reported adverse event cases of methemoglobinemia associated with benzocaine products. Arch Intern Med 2004; 164: Saphir JR, Cooper JA, Kerbavez RJ, et al. Upper airway obstruction after transesophageal echocardiography. J Am Soc Echocardiogr 1997; 10:977. Daniel WG, Erbel R, Kasper W, et al. Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. Circulation 1991; 83:817. Steckelberg JM, Khandheria BK, Anhalt JP, et al. Prospective evaluation of the risk of bacteremia associated with transesophageal echocardiography. Circulation 1991; 84: Min JK, Spencer KT, Furlong KT, et al. Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations. J Am Soc Echocardiogr 2005; 18: Spier BJ, Larue SJ, Teelin TC, et al. Review of complications in a series of patients with known gastro-esophageal varices undergoing transesophageal echocardiography. J Am Soc Echocardiogr 2009; 22:3914.Suriani RJ, Cutrone A, Feierman D, Konstadt S. Intraoperative transesophageal echocardiography during liver transplantation. J Cardiothorac Vasc Anesth 1996; 10: Kane GC, Hoehn SM, Behrenbeck TR, Mulvagh SL. Benzocaineinduced methemoglobinemia based on the Mayo Clinic experience from transesophageal echocardiograms: incidence, outcomes, and predisposing factors. Arch Intern Med 2007; 167: Henry LR, Pizzini M, Delarso B, Ridge JA. Methemoglobinemia: early intraoperative detection by clinical observation. Laryngoscope 2004; 114: Ofili EO, Rich MW. Safety and usefulness of transesophageal echocardiography in persons aged greater than or equal to 70 years. Am J Cardiol 1990; 66:1279.