Anesth Pain Med.  2016 Oct;11(4):337-344. 10.17085/apm.2016.11.4.337.

Transthoracic echocardiography probe in an anesthesiologist's hand: utility in the operating room

Affiliations
  • 1Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. kshwang@amc.seoul.kr

Abstract

With increased availability and feasibility of bedside sonography, point-of-care ultrasonography is a rapidly developing field in many fields of emergency and intensive care medicine. Although anesthesiologists frequently encounter severe hypotension and hypoxia in the operating room and the recovery room, standardized education programs for anesthesiologists regarding bedside transthoracic echocardiography (TTE) do not exist. Compared to transesophageal echocardiography, TTE is completely noninvasive, faster, and it is relatively easier to obtain images therefore, rapid interpretation and diagnosis is possible. In this review, differential diagnosis of severe hypotension with a basic view of TTE is introduced. Anesthesiologists should be encouraged to learn TTE, and thus, they can make quick and accurate decisions about the unclear and unknown causes of severe hypotension and hypoxia.

Keyword

Monitoring; Transthoracic echocadiography

MeSH Terms

Anoxia
Critical Care
Diagnosis
Diagnosis, Differential
Echocardiography*
Echocardiography, Transesophageal
Education
Emergencies
Hand*
Hypotension
Operating Rooms*
Point-of-Care Systems
Recovery Room
Ultrasonography

Figure

  • Fig. 1 Subcostal long and short axis view, Color Doppler shows red-color inflow of superior vena cava (SVC). IVC: inferior vena cava, L: liver, RA: right atrium, RV: right ventricle, LA: left atrium, LV: left ventricle, AO: aorta, TV: tricuspid valve, PA: pulmonary artery.

  • Fig. 2 The mid-papillary view of left ventricle shows hypovolemia. Upper panel: (A) end-diastolic diameter, 3 cm, (B) end-systolic mid-cavity obliteration and kissing ventricle, (C) E/A ratio shows < 1. Lower panel: transmitral E/A ratio as a guidance of fluid administration: fluid challenge shows increase of E/A ratio from < 1 to > 1.

  • Fig. 3 Measurements of left ventricular systolic function, shortening fraction=(LVEDD-LVSD)/LVEDD; fractional area change=(LVEDA-LVSA)/LVEDA; ejection fraction=(LVEDV-LVESV)/LVEDV. LVEDD: left ventricular end-diastolic diameter, LVSD: left ventricular systolic diameter, LVEDA: left ventricular end-diastolic area, LVSA: left ventricular systolic area, LVEDV: left ventricular end-diastolic volume, LVSV: left ventricular systolic volume.

  • Fig. 4 Evaluation of right ventricular function. TAPSE (tricuspid annular plane systolic excursion) < 16 mm, RV tissue Doppler (S’) < 10 cm/s, Fractional area change, (ED-EA)/ED < 35% imply right ventricular dysfunction. ED: end-diastole, ES: end-systole.

  • Fig. 5 Upper panel: The right ventricle (RV) was enlarged as compared with the left ventricle (LV) and the ratio between end-diastolic RV to LV diameter > 0.6. Short axis view of LV shows D-shaped LV, which implies severe pulmonary hypertension due to pulmonary embolism. Lower panel: systolic anterior motion (SAM, arrow) of anterior mitral leaflet obstructs LV outflow track, which shows dagger-shape blood flow in Doppler-echocardiography examination.


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