Intraoperative Focused Cardiac Ultrasound Through the Transhepatic View: A Feasibility Study

Co-Author(s)

• JC

  Jennifer Cha, B.S.

  Medical Student
  Albany Medical College, United States

  Disclosure information not submitted.

First Author(s)

• 

  Nibras Bughrara, MD, FASA,FCCM

  Associate professor of Anesthesiology and Surgery
  Albany Medical College
  Albany, NY

  Disclosure information not submitted.

  Slides

Co-Author(s)

• RS

  Radwan Safa, MD

  Anesthesiology Attending
  Albany Medical Center, United States

  Disclosure information not submitted.
• 

  Aliaksei Pustavoitau, MD, MHS,FCCM

  Associate Professor, ACCM, JHU, SOM
  Johns Hopkins University School of Medicine
  Baltimore, MD

  Disclosure information not submitted.

Title: Intraoperative focused cardiac ultrasound through the transhepatic view: a feasibility study.

Introduction/Hypothesis: Focused cardiac ultrasound (FOCUS) has become an important diagnostic tool in critical scenarios for time-sensitive clinical decision making. One of the main indications for FOCUS is in narrowing the differential diagnosis in patients with undifferentiated shock. This recommendation is limited to the emergency department and intensive care unit for the most part; there is no assessment in the use of FOCUS for shock intraoperatively. Transesophageal echocardiography (TEE) is the current standard of “rescue” imaging modality in any surgical case with refractory hemodynamic instability. We examine the feasibility of FOCUS through the transhepatic view (FOCUS-THV) intraoperatively in patients with hypotension when TEE is contraindicated.

Methods: FOCUS-THV is achieved by placing the ultrasound probe directly on the liver at a 30-degree angle towards the heart through the open surgical wound. This provides a 4-chamber view of the heart. Turning the probe 90-degrees will allow for visualization of the inferior vena cava (IVC) and pleural spaces by rucking the probe left and right. Patients with intraoperative hypotension and TEE contraindication were provided a FOCUS-THV by the surgeon without any previous POCUS training at the verbal instruction of an anesthesiologist trained in FOCUS-THV. Consent was obtained from all patients, or their proxies.

Results: We obtained images in 5 patients who experienced intraoperative hypotension. Of these, 1 was found to be in distributive shock, 1 in obstructive shock, 1 in hemorrhagic, 1 in hypovolemic and 1 in cardiogenic shock. FOCUS-THV was able to guide intraoperative management to stabilize all 5 patients. Image quality assessment by an anesthesiologist proficient in critical care echo deemed 4 studies as “good” and 1 study as “adequate.” The average time to achieve images was 2.2 minutes. We were able to establish MAP > 65 in all patients.

Conclusion: We demonstrated feasibility of performing intraoperative FOCUS-THV by surgeons at the instruction of a trained anesthesiologist during a critical scenario when TEE was contraindicated. Currently, there are no trials comparing the efficiency and reliability of FOCUS-THV against the standard TEE. We plan to ascertain the influence of FOCUS-THV in patient management and outcomes.