Australasian Anaesthesia 2011 - Australian and New Zealand ...

Perioperative Transthoracic Echocardiography in Australasia: Current Position and Future Directions 171Perioperative Transthoracic Echocardiography in Australasia: CurrentPosition and Future DirectionsJOHN FARIS, BSC, DAVMED, FFOM, FANZCA, BA, ASCEXAM, PG DIP CLIN ULTRASOUND.Sir Charles Gairdner Hospital, Perth; Joondalup Hospital; Perth; Fremantle School of Medicine, University of NotreDame Australia; Department of Pharmacology, University of Melbourne, and Royal Melbourne HospitalProfessor Faris is a staff specialist at both Sir Charles Gairdner and Joondalup Hospitals in Perth. After twentyyears in aviation medicine in New Zealand, he changed specialties and joined the anaesthesia training scheme inAuckland, including a cardiac fellowship where he learned transoesophageal echocardiography. He moved to Pertheight years ago and was introduced to transthoracic echocardiography. He further developed this interest joiningthe Ultrasound Education Group at the University of Melbourne. He spends a day each week teaching and reportingechocardiography.COLIN ROYSE, MBBS, MD (MELB), FANZCAAnaesthesia and Pain Management Unit, Department of Pharmacology, University of Melbourne, and Departmentof Anaesthesia and Pain Management, Royal Melbourne HospitalProfessor Colin Royse is a specialist cardiothoracic anaesthetist with academic interests in echocardiography, painmanagement in cardiac surgery, quality of recovery following anaesthesia and surgery, and the evaluation of leftventricular systolic and diastolic function using pressure volume loops. He is Director of the Anaesthesia and PainManagement Unit in the Department of Pharmacology, and Co-Director of the Ultrasound Education Group at theUniversity of Melbourne.YOUR NEXT CASEIt is 9pm at night and you are the consultant on call at a busy teaching hospital. The next case is an 88 year oldman who has fallen and injured his left lower leg requiring evacuation of a large haematoma and split skin graft toclose a residual defect. He had a myocardial infarction six months ago complicated by acute pulmonary oedema,but states that he has recovered. The ECG shows atrial fibrillation and inferior Q waves. Your registrar heard asystolic murmur, but was unconcerned as the patient walked his dog each day (JF personal experience).You have several choices: completely ignore the murmur, delay the case and obtain a transthoracic echocardiography(TTE) examination by the cardiologists, proceed as if this might be significant aortic stenosis, or perform a goaldirectedTTE study?TTE USE IN ANAESTHESIA PRACTICEFor many years since Inge Edler in Sweden in 1953 borrowed a naval reflectoscope to image a heart, cardiacultrasound has largely remained the province of the cardiologists. General ultrasound was for the radiologists.Surgeons and emergency physicians developed the Focused Abdominal Sonography in Trauma (FAST scan) in themid 1990s, including the sub-costal window to image the heart. Parasternal and apical windows were added tobetter diagnose haemodynamic instability in emergency departments and intensive care units. Ultrasound is a veryuseful imaging modality that has crossed traditional craft group usage and in recent times has entered anaesthesiaand critical care practice in a major way.In anaesthesia there were parallel developments of transoesophageal echocardiography (TOE) in cardiac surgery,and ultrasound-guided procedures such as vascular access and regional anaesthesia. Ultrasound machinemanufacturers recognised the potential and produced smaller, cheaper portable models. Phased array probes wereadded providing a practical path for more widespread use of TTE. The non invasive nature of TTE has increasedthe scope into both the preoperative and postoperative arenas. Training courses and workshops for anaesthetistsappeared in TTE rather than just TOE.With these developments, TTE is arguably now ready to come of age.WHY TTE IN ANAESTHESIA?There are many reasons why anaesthetists now seek to perform their own TTE. These include: preoperativeassessments, diagnosis of haemodynamic collapse and haemodynamic monitoring. The most obvious and commonuse of TTE is the preoperative assessment of cardiac disease. Cardiology services may not be available at shortnotice for either perioperative assessments or in the event of a perioperative emergency. Very few Australasianinstitutions, if any, have such a service available at any hour of the day or night.In an ideal world, elective surgery patients would not arrive in the preoperative waiting area with an inadequateassessment of cardiac function. Anaesthetists may resort to increasing invasive monitoring or insist on highdependency or ICU beds after surgery to compensate for potential cardiac disease. Anaesthetist performed TTEmay assist in better risk stratification of patients, and facilitate rational use of invasive monitoring or higher dependencypostoperative care. In this sense, echo is used as a triage tool to determine the most appropriate management forpatients.A second imperative is to guide the diagnosis and management of perioperative haemodynamic instability.Clinical examination alone cannot reliably diagnose the cause of haemodynamic collapse. Hypotension is the