Perioperative echocardiography-guided hemodynamic therapy in high-risk patients: a practical expert approach of hemodynamically focused echocardiography

Abstract

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.

Design of a workshop for focused rescue transesophageal echocardiography in nurse anesthesia: a small-scale mixed methods study

“…Since normal examination (or possibly a hyperdynamic presentation consistent with vasodilation) or hypovolemia were the ndings in approximately 60% of rescue TEE studies performed for noncardiac surgery patients [4], and working recall of the protocol details is important for real time responses to intraoperative crises often under stressful circumstances that may impair memory retrieval [26], this algorithm should be as streamlined as much as possible. More involved echocardiographic protocols for preoperative assessment of high-risk patients represent expert approaches, but they likely are too complex for routine use by novices [27,28]. Furthermore, while greater than one diagnosis is sometimes possible (e.g., refractory hypotension due to hypovolemia in a patient with LV dysfunction), such situations are less common (an example of Occam's razor).…”

Diagnostic Accuracy of Ultrasonographic Respiratory Variation in the Inferior Vena Cava, Subclavian Vein, Internal Jugular Vein, and Femoral Vein Diameter to Predict Fluid Responsiveness: A Systematic Review and Meta-Analysis

“…Seventh, there would exist a “grey zone” to discriminate response to fluid resuscitation even though the ΔIVC is an easy-to-determine quantitative variable. Thus, integrating an additional qualitative sonographic evaluation may be more helpful in future study [ 66 ]. Finally, we included only published original articles and those written in English.…”

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