ECHO DOCTOR: FOCUSED ANESTHESIA ULTRASOUND EXAM

Transcription

1 ECHO DOCTOR: FOCUSED ANESTHESIA ULTRASOUND EXAM Amber Bledsoe, MD Associate Professor Associate Director, Preoperative Clinic Perioperative Echocardiography Team Director of Quality Improvement University of Utah Department of Anesthesiology

2 PERIOPERATIVE MEDICINE

3 THIS TALK ISN T

4 THIS TALK IS

5 MYTHS OF PERIOP TTE 1. For other people 2. Not valuable for your patients 3. Too expensive 4. Too hard

6 STATE OF PERIOPERATIVE ECHO TEE is for us but TTE is for them Who understands perioperative pathophysiology better than us?

7 ARE ANY OF THESE YOUR PATIENTS? Murmur Cancer Obese Hypotensive Meth Abuser Chest Pain Elderly Poor exercise tolerance

8 DOES THIS SOUND FAMILIAR? 74 y/o woman presents for outpatient repair of inguinal hernia H/O stable angina, no other cardiac disease Nuc med stress test, normal EF Harsh systolic murmur and limited exercise tolerance, what to do?

9 PUT THE PROBE ON THE CHEST

10 PUT THE PROBE ON THE CHEST

11 PERIOP AS? SO WHAT? Anesthesiology residents can successfully identify AS after 2 hours of training! Just treat everyone like they have AS!

12 BUT YOUR COLLEAGUE SAYS Do a good physical exam and you won t need echo to diagnose AS! Hmm

13 MEDICAL STUDENTS VS CARDIOLOGISTS Experienced Cardiologist physical exam: 62% sensitive for systolic murmurs, 16% for diastolic TTE Medical students with portable ultrasound Stethoscope of the Present! present! and 18 hrs of training: 93% for systolic and 75% for diastolic!

14 MIGHT THIS PATIENT PRESENT TO AN AMBULATORY CENTER? 56 year-old female presenting for vein stripping BMI = 38 Exercise tolerance = +/- light housework Significant lower extremity edema Venous insufficiency from obesity, cleared by her PCP ( just do a MAC )

15 HAVE YOU SEEN THIS PATIENT?

16 AND THE PA PRESSURES? PASP = 108!

17 SEVERE PHTN AND... RA blood gas: PaO2 = 56, PaCO2 = 51 This patient likely has OHS ~50% 4-year mortality with no surgery 10% in-hospital mortality with surgery Still a low-risk procedure?

18 MAYBE YOU LL SEE THIS GUY 62 year-old man for lumbar microdiscectomy Progressive SOB Very active when his back didn t hurt, so... Cleared by internist No worries?

19 HIS ECHO COULD LOOK LIKE THIS

20 HIS ECHO COULD LOOK LIKE THIS

21 HIS ECHO COULD LOOK LIKE THIS

22 PERIOPERATIVE HEART FAILURE > 5 million Americans have heart failure 18% of Medicare patients undergoing noncardiac surgery have heart failure 5 year mortality 50-70% without surgery 30 day mortality 8% with surgery

23 IN THE PACU 62 year-old man, smoker, HLD Straightforward lap chole Now complaining of nausea and chest pain

24 IN THE PACU Blood pressure: 144/72 > 92/48 HR: 70 bpm SpO2: 88% ECG: NS with ST changes Transfer to cath lab at the main hospital?

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26 UGH 30 y/o female, suspected breast CA, now presenting for biopsy Prior marathon runner, last was 18 months ago DOS reports paralyzing fatigue, dyspnea, feels like she s going to die And then you see this

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28 THESE ARE THE THINGS WE SEE

29 BUT THE SURGEONS WILL YELL AT ME Elderly hip fracture patients Anesthesiologist-performed preop TTE ANESTHESIA TTE SAVES LIVES! Did not delay entry into OR Less mortality at 30 days (5% vs 15%) Less mortality at 12 months (17% vs 33%) What are we waiting for?

30 I DON T HAVE A TTE PROBE! 62 year old woman, right rotator cuff repair She s very thin You place a (challenging) interscalene block 45 minutes into the case Blood pressure: LOW Vent pressure: HIGH

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33 YOU CAN DO THIS!!

34 A RESIDENT S FIRST ECHO < 9 SECONDS

35 A COUPLE OF MONTHS AGO

36 AT MY HOUSE PERIOPERATIVE MEDICINE

37 WHAT S REQUIRED? Motivation Equipment (you may have it already!) Training Continuing support and QA

38 SUMMARY Echocardiography can be comprehensive, and overwhelming Bedside POC ultrasound can be simple, straightforward, and incredibly useful for both inpatient and outpatient settings It can help you take better care of patients

39 PERIOPERATIVE MEDICINE

40 Your Photo Here PERIOPERATIVE MEDICINE

41 Zimmerman JM, Coker BJ. The Nuts and Bolts of Performing Focused Cardiovascular Ultrasound (FoCUS). Anesth Analg. 2017;124(3): (Description of how to perform FoCUS with lots of videos and examples) UNIVERSITY OF UTAH HEALTH, 2017

42 REFERENCES Lots of videos showing how to perform and interpret bedside echo Zimmerman JM, Coker BJ. The Nuts and Bolts of Performing Focused Cardiovascular Ultrasound (FoCUS). Anesth Analg. 2017;124(3): Description of how to perform FoCUS with lots of videos and examples Coker BJ, Zimmerman JM. Why Anesthesiologists Must Incorporate Focused Cardiac Ultrasound Into Daily Practice. Anesth Analg. 2017;124(3): Recent review of FoCUS for anesthesiologists Canty DJ, Royse CF, Kilpatrick D, Bowman L, Royse AG. The impact of focused transthoracic echocardiography in the preoperative clinic. Anaesthesia. 2012;67(6): Anesthesiologist-performed TTE in a preoperative clinic is feasible and frequently alters management, so get cracking! Kobal SL, Trento L, Baharami S, Tolstrup K, Naqvi TZ, Cercek B, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. AJC 2005;96: Medical students with portable ultrasound evaluate valve lesions better than cardiologists with stethoscopes, awesome! Cowie B, Kluger R. Evaluation of systolic murmurs using transthoracic echocardiography by anaesthetic trainees. Anaesthesia 2011;66(9): Anesthesia residents can easily be trained to successfully evaluate for significant AS

43 REFERENCES Chau EHL, Lam D, Wong J, Mokhlesi B, Chung F. Obesity hypoventilation syndrome: a review of epidemiology, pathophysiology, and perioperative considerations. Anesthesiology 2012;117(1): Excellent review of obesity hypoventilation syndrome, including pathophysiology, morbidity and mortality Lai H-C, Lai H-C, Wang K-Y, Lee W-L, Ting C-T, Liu T-J. Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery. Br J Anaesth 2007;99(2): Fairly small series, but it does show a nearly 10% in-hospital mortality after non-cardiac surgery in patients with severe PHTN Hammill B, Curtis L, Bennett-Guerrero E, et al. Impact of heart failure on patients undergoing major noncardiac surgery. Anesthesiology. 2008;108(4): Large series of elderly patients undergoing non-cardiac surgery. Mortality with CHF was twice that with CAD and three times that with neither. 20% prevalence of CHF! Flu W-J, van Kuijk J-P, Hoeks SE, et al. Prognostic implications of asymptomatic left ventricular dysfunction in patients undergoing vascular surgery. Anesthesiology. 2010;112(6): Asymptomatic systolic or diastolic LV dysfunction increases mortality. Loxdale SJ, Sneyd JR, Donovan A, Werrett G, Viira DJ. The role of routine pre-operative bedside echocardiography in detecting aortic stenosis in patients with a hip fracture*. Anaesthesia 2011;67(1):51 4. Significant aortic stenosis and LV systolic dysfunction are highly prevalent among the elderly hip fracture population

44 REFERENCES van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA. Mortality and Readmission of Patients With Heart Failure, Atrial Fibrillation, or Coronary Artery Disease Undergoing Noncardiac Surgery: An Analysis of Patients. Circulation. 2011;124(3): Shockingly high mortality among patients undergoing NCS with CHF (8-9!) Fonseca C, et al. The diagnosis of heart failure in primary care: value of symptoms and signs. Eur J Heart Fail 2004;6(6): Interesting evaluation of the poor sensitivity and specificity of history and physician in the diagnosis of heart failure Kim, T.-H., et al. (2013). Echocardiographic predictor of acute heart failure after spine surgery: a novel tissue Doppler index associated with a potentially fatal complication of the operation. The Spine Journal. 2013;4(5): Preoperative diastolic dysfunction predicts postop heart failure. Not rocket science, and other specialties are realizing it too. Canty DJ, Royse CF, Kilpatrick D, Bowyer A, Royse AG. The impact on cardiac diagnosis and mortality of focused transthoracic echocardiography in hip fracture surgery patients with increased risk of cardiac disease: a retrospective cohort study. Anaesthesia 2012;67(11): Small study, but it shows that anesthesiologist-performed TTE can save lives! And you can do it!

45 REFERENCES Bonow RO, et al. ACC 2017 Appropriate Use Criteria for the Treatment of Patients With Severe Aortic Stenosis. J Am Coll Cardiol 70: , 2017 Recommendation on intervention in patients with severe AS, periop and otherwise Fleisher LA, et al ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol 2014;64:e