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Canadian Journal of Anesthesia 49:287-293 (2002)
© Canadian Anesthesiologists' Society, 2002
Cardiothoracic Anesthesia, Respiration and Airway

Perioperative use of transesophageal echocardiography by anesthesiologists: impact in noncardiac surgery and in the intensive care unit

[L'utilisation périopératoire de l'échocardiographie transoesophagienne par les anesthésiologistes : les répercussions en chirurgie non cardiaque et à l'unité des soins intensifs]

André Y. Denault, MD FRCPC*, Pierre Couture, MD FRCPC*, Sylvie McKenty, MD FRCPC{dagger}, Daniel Boudreault, MD FRCPC{dagger}, François Plante, MD FRCPC{dagger}, Roger Perron, RRT{dagger}, Denis Babin, MSc* and Jean Buithieu, MD FRCPC{ddagger}

* From the Department of Anesthesiology, Montreal Heart Institute and the Departments of Anesthesiology and
{dagger} Medicine,
{ddagger} Centre Hospitalier de l'Université de Montreal (CHUM), Hôpital Notre-Dame, Montreal, Quebec, Canada.

Dr. André Y. Denault, Department of Anesthesiology, Montreal Heart Institute, 5000 Bélanger Street East, Montreal, Quebec H1T 1C8, Canada. Phone: 514-376-3330, ext. 3732; Fax: 514-376-8784; E-mail: denault{at}videotron.ca


   Abstract
TOP
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Background: The American Society of Anesthesiologists (ASA) has published practice guidelines for the use of perioperative transesophageal echocardiography (TEE) but the role and impact of TEE performed by anesthesiologists outside the cardiac operating room (OR) is still poorly explored. We report our experience in the use of TEE in the noncardiac OR, the recovery room and in the intensive care unit (ICU) in a university hospital, and analyze the impact of TEE on clinical decision making.

Methods: Two hundred fourteen patients were included and TEE indications were classified prospectively according to the ASA guidelines. The examinations and data sheets were reviewed by two anesthesiologists with advanced training in TEE. For each examination, it was noted if TEE altered the management according to five groups: 1) changing medical therapy; 2) changing surgical therapy; 3) confirmation of a diagnosis; 4) positioning of an intravascular device; and 5) TEE used as a substitute to a pulmonary artery catheter.

Results: Eighty-nine (37%), 67 (31%) and 58 (27%) patients had category I, II and III indications. The impact was more significant in category I where TEE altered therapy 60% of the time compared with 31% and 21% for categories II and III (P < 0.001). The most frequent reason for changing management was a modification in medical therapy in 53 instances (45%).

Conclusion: Our results confirm a greater impact of TEE performed by anesthesiologists on clinical management for category I compared to category II and III indications in the noncardiac OR surgical setting and in the ICU.


   Introduction
TOP
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
IN 1996 guidelines for the use of perioperative transesophageal echocardiography (TEE) were published from a consensus conference by the American Society of Anesthesiologists and the American College of Cardiology.1 It appears from these guidelines that the impact of TEE will occur mostly during cardiac surgery. However, there is a growing interest in the use of TEE by the anesthesiologist in the noncardiac surgical setting2,3 and in the intensive care unit (ICU).4 The impact of TEE and the noncardiac procedures which are most likely to benefit from this monitoring technique are not well defined. In addition, the role of ASA guidelines for TEE has not been validated in a large number of patients in which TEE was performed in the noncardiac surgical setting.

Since the introduction of TEE in our practice in 1990 at Notre-Dame Hospital, we previously reported our experience in cardiac surgery5 but the role and impact of TEE performed solely by anesthesiologists outside of the cardiac operating theater is still poorly explored. We now are reporting our experience in the use of perioperative TEE in the noncardiac operating room (OR), the recovery room and in the ICU to determine the relative impact of category-based TEE indications.


   Methods
TOP
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
Following approval by our Ethics Committee, all TEE examinations performed by anesthesiologists from October 1993 to February 1997 (41 months) were collected and classified in a database. Category I, II and III indications were defined according to the ASA guidelines on perioperative TEE.1 A category I is a condition in which the use of TEE is supported by the strongest evidence or expert opinion, a category II is associated with weaker evidence and a category III has little current scientific or expert support. TEE examinations were performed in the OR, the recovery room and the surgical ICU (SICU). Those performed in the cardiac OR were excluded. Our SICU is a mixed ICU mainly occupied by postoperative general surgery, neurosurgery and cardiac surgery patients.

TEE examinations were done using a multiplane 5-MHz transducer (Sonos 1500, Hewlett-Packard, Andover, MA, USA) or a uniplane probe (Sonoline CF, Siemens, Pleasanton, CA, USA) and included two-dimensional imaging of the aorta, a mid-esophageal four-chamber and a short-axis transgastric view. The latter view was used for continuous monitoring during the procedure. A mid-esophageal two-chamber and a long axis transgastric view of the left ventricle and left ventricular outflow tract were also examined when the multiplane probe was used. Color Doppler interrogation of the mitral, aortic and tricuspid valve was also performed routinely. A cardiologist trained in echocardiography (J.B.) was requested if necessary for more specific examinations such as the evaluation of unexpected severe valvular dysfunction.

At the time of examination, it was noted if TEE changed the course of the current therapy or management. This was further classified into five groups: 1) TEE findings altered medical therapy, for instance, by adding an inotrope or volume expansion; 2) TEE lead to an unplanned surgical intervention; 3) TEE confirmed or invalidated a diagnosis which could have lead to a surgical intervention; 4) TEE was useful in positioning intravascular devices; 5) TEE was used as a substitute to a pulmonary artery catheter (PAC). Nine of our anesthesiologists have basic training in TEE and two have advanced training with National Board Certification (A.D., P.C.). However, all TEE examinations and data sheets were supervised and reviewed by those with advanced training. Our interobserver variability in the evaluation of cardiac function has been published.6–8

A consensus had to be reached between the two TEE reviewers (A.D., P.C.) for an examination to be accepted as altering medical therapy, otherwise it was rejected. It was rejected if no explanation was provided or no consensus reached. TEE modified a surgical intervention only if the surgeon stated, at the time of examination, that without TEE, he would not have performed or modified his intervention. Some examinations may have been included in more than one subcategory, for instance if TEE confirmed the unsuspected presence of a patent foramen ovale during spinal neurosurgery (category III) and modified the surgical approach [lateral decubitus instead of supine position (category I)].

Statistical analysis
Chi-square analysis was used to compare the impact of TEE according to the category and group indications. Analysis of variance was used to compare age of the patients between the different groups. Statistical analysis was done using the Statview 4.1 program (Abacus Inc, Berkely, CA, USA). P < 0.05 was considered significant.


   Results
TOP
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
From a total of 1,065 TEE exams, 214 (20%) consecutive examinations were classified as noncardiac surgery and reviewed. From these, 155 (72%) were performed during noncardiac surgery, four (2%) in the recovery room and 55 (26%) in the SICU. Eighty-nine patients (37%) had category I indications, 67 patients (31%) had category II indications and 58 patients (27%) were considered category III (Table IGo). Category I (n = 89 patients) were the most common indications for the use of TEE compared to category II (P = 0.027) and III (P = 0.0046).


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  		TABLE I Population characteristics and TEE exams
 
TEE changed management in 86 patients (40%) with a total of 118 modifications. From these 86 patients, 43 were in the OR, three in the recovery room and 40 in the ICU. Patients with changes in management were more often in category I (60%) vs II (31%) or III (21%; P < 0.001). No difference in age and sex was observed in those three categories and also in those with or without modified therapy.

In the OR, 20 patients (46%) with modified therapy were of category I and this was more frequent than in category II (P = 0.02) and III (P = 0.004). In the SICU, 31 (77%) patients with modified therapy were category I.

Figure 1Go illustrates the distribution of modifications. In 53 instances (45%) the modification in management was secondary to a change in medical therapy. Twenty-one modifications in 19 patients (18%) led to unplanned surgical reinterventions based on TEE findings which are detailed in Table IIGo. Confirming or invalidating of a diagnosis was found to change management in 35 instances (30%). The use of TEE or as a substitute to a PAC or for positioning intravascular devices was found to be useful in nine instances (8%).



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  		FIGURE 1 Distribution of the total number of modifications which are detailed according to category I through III indications for TEE.

 

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  		TABLE II Summary of surgical modifications related to the use of TEE
 
When TEE changed therapy, unplanned surgical reinterventions (10% vs 13%) as a result of TEE were as common in category I as II but a more significant impact was found for altering medical therapy (36% vs 21%) in category I than II (P < 0.001) and I vs III (36% vs 12%; P < 0.001; Figure 2Go).



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  		FIGURE 2 Medical and surgical impact according to indication category. (*P < 0.001 for medical therapy in category I vs II and I vs III; n = number).

 
General, vascular and thoracic surgery represented 83% of our use of TEE in the noncardiac surgical setting. Therapy was more commonly modified in general surgery compared with vascular (P = 0.014) and thoracic (P = 0.043).


   Discussion
TOP
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
In this study using the ASA guidelines, we observed that TEE performed by anesthesiologists can have an impact of the clinical management of patients undergoing noncardiac surgical procedures, in the recovery room and in the ICU. This was apparent mostly in category I indications. The impact of TEE in the noncardiac setting was even more important than that we had observed in cardiac surgery.5 These findings extend the role of TEE outside the cardiac surgical arena. This study represents a large anesthesiologists' experience in the use of TEE in the noncardiac surgical and in the ICU setting using the ASA guidelines.1 While TEE is most likely to be useful in category I for altering medical therapy, we did not observe any difference between categories I and II for surgical management. This could be explained by our sample size and also because, in the ASA guidelines, few situations in the noncardiac surgical setting (apart from hemodynamic instability) are associated with a category I indication. We also observed an impact of TEE in category III indications in 12 patients (21%). This was associated with the use of TEE as a monitoring tool in the OR and in the ICU. This group represents situations in which the role of TEE is being explored and, consequently, were classified as category III.

The only similar noncardiac study in which anesthesiologists performed TEE in the OR was reported by Suriani and coworkers2 in which the role of TEE was explored in 123 noncardiac surgery patients. They were classified as consultative if performed by a consultant or non-consultative when performed by the attending anesthesiologists. The consequences of TEE were rated as major, minor, limited and no impact. A major impact was defined as treatment of a life-threatening event, changing surgical technique or anesthetic management or leading to further evaluation in the postoperative period. Overall, the authors observed an 81% impact and a major impact was found in 15% of their patients. This is higher than our overall impact of 41% but similar to the major impact of 19% (medical and surgical) observed when considering only our noncardiac patients in the OR (n = 155). In agreement with Suriani's conclusions, we also found that the major advantage of TEE was its rapid diagnostic capability during the period of hemodynamic instability.

Other studies included noncardiac patients monitored with TEE in the OR. Brandt described the use of intraoperative TEE in patients undergoing cardiac (n = 46) and noncardiac surgery (n = 20).9 The indications in noncardiac surgery were mainly hemodynamic instability in 50%. In four of these noncardiac patients undergoing vascular surgery, TEE altered the operative procedure. Kolev studied the influence of TEE on intraoperative decision making using the ASA guidelines.3 This European study included 224 patients, undergoing cardiac and noncardiac surgery, from nine participating centres. Our results are in agreement with their observations, resulting in a 30% change in overall management, with a greater impact in category I than category II.

Studies published in the ICU support our findings (Table IIIGo). The clinical experience of several authors demonstrates that TEE in the ICU picks up unexpected clinical findings in 25% to 59% of patients and has a direct influence on the therapeutic decisions in 8% to 24% of cases.10–16 However, anesthesiologists trained in TEE were not reported as those performing the echocardiographic examination in most of these studies.


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  		TABLE III Summary of studies on the impact of TEE in noncardiac surgery and in the ICU
 
Limitations
The greater impact of TEE in noncardiac surgery compared to cardiac surgery can be explained by the non-routine use of TEE in these patients. Consequently, a bias could be introduced as patients are selected because they are more likely to benefit from TEE. Using routine TEE for noncardiac surgery would have yielded a lower impact but this does not represent our practice. In the noncardiac surgery setting, we use TEE mostly in category I indications, and this supports that the use of TEE in this context has a significant impact. Similarly, the role of TEE in the ICU is clearly established during critical situations. We did not exclude postoperative cardiac surgery patients because of our mixed ICU population. However, this could have reduced the overall surgical impact in the ICU. We strongly believe that TEE has the potential to become an essential tool for noncardiac anesthesiologists in unstable patients undergoing noncardiac surgery and in the ICU because of its rapid diagnostic capabilities. This advantage of the TEE has to be weighed against the cost and size of the equipment and the expertise required at the bedside for continuous monitoring. At present, this type of monitoring is available mostly in the cardiac operating suites of large centres. Certification by the National Board of Echocardiography is now available for perioperative TEE and may become mandatory for anesthesiologists eager to make use of this diagnostic and monitoring modality.

In summary, TEE performed by anesthesiologists can have a significant impact in the non-cardiac surgical theater, in the recovery room and the ICU. TEE utilization has a greater impact for category I than categories II or III of the ASA indications and results mainly in modifications of medical therapy.


   Acknowledgments
 
This study was supported by the "Plan de Pratiques des anesthésiologistes de l'Hôpital Notre-Dame du CHUM et de l'Institut de Cardiologie de Montréal, the "Bourse Sheridan de la Société canadienne d'anesthésiologie" and the "Fondation d'anesthésiologie du Québec de l'Association des anesthésistes du Québec". We thank Luce Bégin for secretarial support.

Revision received November 16, 2001. Accepted for publication October 26, 2001.


   References
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 Discussion
 References
 
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2 Suriani RJ, Neustein S, Shore-Lesserson L, Konstadt S. Intraoperative transesophageal echocardiography during noncardiac surgery. J Cardiothorac Vasc Anesth 1998; 12: 274–80.[Medline]

3 Kolev N, Brase R, Swanevelder J, et al. The influence of transoesophageal echocardiography on intra-operative decision making. A European multicentre study. European Perioperative TOE Research Group. Anaesthesia 1998; 53: 767–73.[Medline]

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