Connie Lorette, PhD, CRNA Intraoperative monitoring ASE/SCA assess - PowerPoint PPT Presentation

Connie Lorette, PhD, CRNA

§ Intraoperative monitoring § ASE/SCA assess 20 view § PTE assesses 11 views § Hemodynamic or ventilatory instability § Ventricular size and function § Valvular anatomy and function § Volume status § Pericardial abnormalities § Complication from invasive procedures § Clinical impact or etiology of pulmonary dysfunction

§ Probe insertion § Displacing mandible anteriorly and inserting probe in the midline § Direct laryngoscopy § Never force § Tip in neutral § Control wheels unlocked § Suction gastric fluid

§ Probe Manipulation § Advancing and withdrawing the probe – rotating probe to the right and left § Axial rotation forward from 0 – 180º § Anteflexion and retroflexion § Lateral flexion to the right and left

§ Image display § Transducer location is at the top of the images § Near field at the top § Far field at the bottom § At 0 degrees the image is directed anteriorly from the esophagus to the heart § Patients right side is presented on the left side of the image display

§ Beating heart and breathing § Axial rotations of the heart § Cardiac structures are at different orientations and angles to each other § The left main bronchus is anterior to the arch of the aorta – unable to fully assess the ascending portion of the aorta § Variations between individuals in the anatomic relationship of the esophagus to the heart

§ Dental and/or oral trauma § Laryngeal dysfunction § Postoperative aspiration § ETT displacement § Bronchial compression in infants § Aortic compression in infants § Upper GI bleeding § Pharyngeal perforation § Esophageal perforation

§ Transducer frequency § Adjust to the highest frequency that provides adequate depth of penetration to the structure being examined § Image depth § Adjusted to center the structure being examined in the display § Image gain and dynamic range § Adjusted so that the blood in the chambers appears nearly black and is distinct from the shades of gray representing tissue § Time gain compensation § Adjusted so that there is uniform brightness from the near field to the far field of image § CFD gain § Adjusted to a threshold that just eliminates any background noise within the color sector

§ Two-dimensional imaging to examine cardiac anatomy § Color flow Doppler imaging to visualize blood flow velocities § Pulse-wave to measure blood flow velocities at specific locations § Continuous wave to measure high velocities that exceed the limits of pulsed Doppler

§ Probe depth = 30 – 40 cm § Multiplane angle = 0º - 20º § Structure seen § RA – IAS – LA – MV – TV – LV (septal/lateral walls) – RV (septal/free walls) – interventricular septum § Diagnostic information § Chamber volume and function, MV and TV function, assessment of global LV and RV systolic function and of regional LV inferoseptal and anterolateral walls § Color flow Doppler § Nyquist limit set to 50 – 60 cm/sec § MV and TV valvular pathology § IAS to identify shunt flow

§ Probe depth = 30 – 40 cm § Multiplane angle = 80º - 100º § Structures seen § LA – MV – LV – LAA – coronary sinus – left circumflex artery § Diagnostic information § LA/LV size, global and regional LV function, MV structure and function, and regional assessment of the LV anterior and inferior walls. § Thrombus in the LAA § Color flow Doppler § Nyquist limit 50 – 60 cm/sec § MV pathology

§ Probe depth = 30 – 40 cm § Multiplane angle = 120º – 160º § Structures seen § LA – MV – LV (infero-lateral and antero-septal walls) – intraventricular septum – LVOT – AV - proximal ascending aorta - RV § Diagnostic information § Chamber volume and function, LA/LV size, MV and AV function, LVOT pathology, and Ascending Aortic dissection/aneurysm § Color flow Doppler § Nyquist limit 50 – 60 cm/sec § MV , LVOT, and AV pathology (regurgitation or stenosis)

§ Probe depth = 30 – 40 cm § Multiplane angle = 100 - 150° § Structures seen § Aorta - main PA – SVC - pulmonic valve - RV outflow tract § Diagnostic information § Aortic dissection/aneurysm § Proximal pulmonary emboli

§ Probe depth = 30 – 40 cm § Multiplane angle = 20 – 40° § Structures seen § Proximal ascending aorta – SVC – PV - proximal main PA – Right PA (left PA is obscured by the left mainstem bronchus) § Diagnostic information § Proximal pulmonary emboli § Ascending aortic dissection § Central lines in the SVC § Swan Ganz position in the PA

§ Probe depth = 30 – 40 cm § Multiplane angle = 0 – 60° § Structures seen § LA – RA – IAS – AV – Right, Left and Non Coronary Cusps (AV) – TV – RV - RVOT § Diagnostic information § AV structure and function, and Coronary take-offs § Color flow Doppler § Nyquist 50 – 60 cm/sec § AI

§ Probe depth = 0 – 40 cm § Multiplane angle = 60 – 90° § Structures seen § LA – RA – IAS – TV – AV – RV free wall, RV outflow tract – PV - proximal main PA § Diagnostic information § RV size, volume and function § TV and PV structure and function § Color flow Doppler § Nyquist 50 – 60 cm/sec § TV and PV in identification of valvular pathology

§ Probe depth = 30 – 35 cm § Multiplane angle = 90 – 110° § Structures seen § LA – RA - RA appendage - Intra-atrial septum – SVC – IVC § Diagnostic information § Catheters or wires from SVC or IVC (CVP, PA catheter, pacemaker, and venous cannula) § Masses or obstruction to SVC and/or IVC § Intra-atrial septum aneurysm § ASD or PFO § Color flow Doppler § Nyquist 20 – 30 cm/sec § PFO § Right-to-left shunt

§ Probe depth = 40 – 55 cm § Multiplane angle = 0 – 20° § Structures seen § LV – RV - All segments of the LV - Posteromedial papillary muscle - anterolateral papillary muscle § Diagnostic information § LV/RV volume status, systolic function, regional wall motion, LV size, LV hypertrophy, pericardial effusion

§ Probe depth = 30 – 35 cm § Image depth should be decreased to enlarge the size of the aorta and the focus set to be in the near field. § Gain should be increased in the near field to optimize imaging. § Multiplane angle § SAX view 0° § LAX view 90° § Structures seen § Descending aorta - left pleural space § Diagnostic information § Aortic pathology, aortic diameter, aortic atherosclerosis and aortic dissection § Positioning of IABP § Left pleural fluid/hemothorax § Right pleural effusion may be imaged by turning the probe further clockwise to image the right chest

§ Qualitative visual estimation of systolic function § ME four-chamber, ME two-chamber, and ME LAX views § TG midpapillary SAX view https://video.search.yahoo.com/yhs/search?fr=yhs-sz-001&hsimp=yhs- 001&hspart=sz&p=video+clip+of+TEE+global+LV+function - id=3&vid=f3cda26de7ce62054df03fa2cbf5aa12&action=view

§ Assessing hypotensive patients § Liver transplantation § Pulmonary hypertension

§ Hemodynamic instability § Acute blood loss § LVED diameter and area obtained in the TG midpapillary SAX view § LV cavity size § Response to fluid therapy § https://video.search.yahoo.com/yhs/search?fr=yhs-sz-001&hsimp=yhs- 001&hspart=sz&p=Video+clip+of+Transesophageal+echo+with+hypovolemia - id=2&vid=4417f1316e683d3e4dcf0dd1676b4b84&action=click

§ Color flow Doppler assessment of valvular regurgitation for the AV , MV , TV , and PV § Differentiation of mild from moderate versus severe degrees of insufficiency with visual inspection of regurgitant jet area § Stenotic lesions can be visualized through leaflet motion and using continous wave Doppler beam. https://www.youtube.com/watch?time_continue=5&v=rgY7Ic_9K0M

§ Surgery and trauma pose an increased risk for PE § PE acute and central § Signs of RV dysfunction § RV dilation and hypokinesis § Atypical regional wall motion abnormalities of the RV free wall https://www.youtube.com/watch?v=mxcIx5xUV3k

§ VAE during craniotomies in the sitting position – incidence as high as 76% § Vast majority are small with little clinical significance § Massive VAE and paradoxical embolism across a PFO can be catastrophic § TEE provides real-time data and visual quantification of VAE – more sensitive than precordial Doppler § Pre-surgical detection of a right-to-left shunt https://www.youtube.com/watch?v=GAMMXFN60IQ

§ Trauma (blunt or penetrating thoracic trauma) § Iatrogenic trauma (during invasive procedures) § Rapid accumulation of pericardial fluid can result in significant hemodynamic instability § TEE can facilitate pericardiocentesis https://www.youtube.com/watch?v=hgTaue_Fy7E

§ Reeves S, Finley A, Skubas j, Swaminathan M, Whitely W , et al. Basic perioperative TEE: A consensus statement of the ASE and SCA. Journal of American Society of Echocardiography 2013; 26: 443 – 56. § Reeves S & Perrino A (2014). A Practical Approach to Transesophageal Echocardiography 3 rd ed. Philadelphia PA: Lippincott Williams & Wilkins. § Siderbotham d, Merry A, Legget M, & Edwards M (2011). Practical Perioperative Transesophageal Echocardiography with Critical Care Echocardiography 2 nd ed. Philadelphia PA: Saunders, Elsevier Inc.