The impact of pre‐operative focused transthoracic echocardiography in emergency non‐cardiac surgery patients with known or risk of cardiac disease

Abstract

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

Unrecognized tamponade diagnosed pre-induction by focused echocardiography

“…Furthermore, the information is readily available at the patient's bedside and can be used immediately by the treating physician to guide patient management. 25 In this complex cardiac patient presenting for endoscopic sinus surgery, history, physical exam, and traditional investigations alone did not establish the diagnosis of cardiac tamponade. A focused bedside TTE performed by the anesthesiologist just prior to induction of anesthesia prevented potentially disastrous hemodynamic compromise had cardiac tamponade gone unrecognized.…”

A systematic review of transthoracic and transesophageal echocardiography in non-cardiac surgery: implications for point-of-care ultrasound education in the operating room

“…[9][10][11][12][13][14][15][16][17][18][19][20] All the studies were reported as comprehensive examinations, which was reflected in the broad diversity of diagnoses. As described previously, preoperative exams occurred immediately prior to induction of anesthesia and data from pre-assessment clinic exams were not included.…”

Perioperative Echocardiographic Diagnosis of Regional Wall Motion Abnormalities: Not All of Them are Ischemic!

“…8 A prospective study of 99 patients presenting for emergency noncardiac surgery found that preoperative focused TTE screening changed the cardiac diagnosis compared with clinical examination in 67% of patients, and changed anesthesia management in 44%. 9 In another study of hip fracture surgery patients, preoperative focused TTE changed the cardiac diagnosis in 78% and the management plan in 52%, with lower mortality in the focused TTE group compared with historical controls (not a controlled study). 10 Sufficiently powered randomized controlled studies are needed to characterize populations in which preoperative screening TTE might improve outcomes.…”