SummaryHip fracture surgery is associated with a high rate of mortality and morbidity; heart disease is the leading cause and is often unrecognised and inadequately treated. Pre-operative focused transthoracic echocardiography by anaesthetists frequently influences management, but mortality outcome studies have not been performed to date. Mortality over the 12 months after hip fracture surgery, in 64 patients at risk of cardiac disease who received pre-operative echocardiography, was compared with 66 randomised historical controls who did not receive echocardiography. Mortality was lower in the group that received echocardiography over the 30 days (4.7% vs 15.2%, log rank p = 0.047) and 12 months after surgery (17.1% vs 33.3%, log rank p = 0.031). Hazard of death was also reduced with pre-operative echocardiography over 12 months after adjustment for known risk factors (hazard ratio 0.41, 95% CI 0.2-0.85, p = 0.016). Pre-operative echocardiography was not associated with a delay in surgery. These data support a randomised controlled trial to confirm these findings.

Anaesthetist-performed point-of-care TTE and thoracic ultrasound may have a high clinical impact on the perioperative management of patients scheduled for non-cardiac surgery.

SummaryThis prospective observational study investigated the effect of focused transthoracic echocardiography in 99 patients who had suspected cardiac disease or were ‡ 65 years old, and were scheduled for emergency non-cardiac surgery. The treating anaesthetist completed a diagnosis and management plan before and after transthoracic echocardiography, which was performed by an independent operator. Clinical examination rated cardiac disease present in 75%; the remainder were asymptomatic. The cardiac diagnosis was changed in 67% and the management plan in 44% of patients after echocardiography. Cardiac disease was identified by echocardiography in 64% of patients, which led to a step-up of treatment in 36% (4% delay for cardiology referral, 2% altered surgery, 4% intensive care and 26% intra-operative haemodynamic management changes). Absence of cardiac disease in 36% resulted in a step-down of treatment in 8% (no referral 3%, intensive care 1% or haemodynamic treatment 4%). Pre-operative focused transthoracic echocardiography in patients admitted for emergency surgery and with known cardiac disease or suspected to be at risk of cardiac disease frequently alters diagnosis and management. Cardiac complications are a leading cause of perioperative mortality [1,2]. Patients with cardiac disease requiring emergency surgery have a higher incidence of peri-operative complications [2], especially if surgery is performed after hours [3] or if patients are elderly [4]. Accurate pre-operative cardiac assessment is important to devise the most appropriate anaesthetic plan [2]. Aortic stenosis, common in the hip fracture population [5], and pulmonary hypertension are significant risk factors for mortality [6,7], but diagnosis is unreliable without echocardiography [8,9]. In addition, other abnormal haemodynamic states such as hypovolaemia, left ventricular systolic and ⁄ or diastolic failure, right heart failure and vasodilatation (for example, in sepsis) often accompany acute surgical disease, and may contribute to impaired cardiac output and tissue

Summary Focused echocardiography is becoming a widely used tool to aid clinical assessment by anaesthetists and critical care physicians. At the present time, most physicians are not yet trained in focused echocardiography or believe that it may result in adverse outcomes by delaying, or otherwise interfering with, time‐critical patient management. We performed a systematic review of electronic databases on the topic of focused echocardiography in anaesthesia and critical care. We found 18 full text articles, which consistently reported that focused echocardiography may be used to identify or exclude previously unrecognised or suspected cardiac abnormalities, resulting in frequent important changes to patient management. However, most of the articles were observational studies with inherent design flaws. Thirteen prospective studies, including two that measured patient outcome, were supportive of focused echocardiography, whereas five retrospective cohort studies, including three outcome studies, did not support focused echocardiography. There is an urgent requirement for randomised controlled trials.

SummaryHigh frequency jet ventilation has been shown to be beneficial during extra‐corporeal shock wave lithotripsy as it reduces urinary calculus movement which increases lithotripsy efficiency with better utilisation of shockwave energy and less patient exposure to tissue trauma. In all reports, sub‐glottic high frequency jet ventilation was delivered through a tracheal tube or a jet catheter requiring paralysis and direct laryngoscopy. In this study, a simple method using supraglottic jet ventilation through a laryngeal mask attached to a circle absorber anaesthetic breathing system is described. The technique avoids the need for dense neuromuscular blockade for laryngoscopy and the potential complications associated with sub‐glottic instrumentation and sub‐glottic jet ventilation. The technique was successfully employed in a series of patients undergoing lithotripsy under general anaesthesia as an outpatient procedure.

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