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Representative transesophageal echocardiography findings in obstetric patients with severe hemodynamic instability. (A) Modified mid-esophageal four chamber view: right atrial (RA) dilatation and bowing of the interatrial septum consistent with elevated right heart pressures due to pulmonary embolism. (B) Mid-esophageal right ventricular (RV) inflow-outflow view: visible clot burden in the right (RA) and left atrium (LA) after amniotic fluid embolism complicated by disseminated intravascular coagulation. (C) Transgastric mid-papillary short axis view at end systole: hyperdynamic, underfilled left ventricle (LV) with collapse of the ventricular cavity due to hypovolemia related to postpartum hemorrhage. (D) M-mode analysis of transgastric mid-papillary short axis view: near contact between the anterior and inferior LV walls with respiratory variation consistent with hypovolemia.
Source publication
The obstetric population has an increasing incidence of comorbid conditions. These, coupled with the possibility of acute embolic events involving air, amniotic fluid, and thrombus, increase the likelihood of hemodynamic instability. Although the utility of transesophageal echocardiography to guide management in cardiac and high-risk, non-cardiac s...
Context in source publication
Context 1
... total of 818 emergent TEE examinations were per- formed in non-cardiac surgical patients, including 10 peripartum patients who experienced refractory hemo- dynamic instability (Fig. 1). The 10 patients ranged in age from 17 to 41 years (mean 32.5 years) and parity from 0 to 4 (Table 1). Seven of the 10 patients were pre- operatively classified as ASA physical status 1, two patients as ASA 3, and one as ASA 4. Of the ASA 3 patients, one had a diagnosis of adriamycin-induced car- diomyopathy with an ejection fraction ...
Citations
... Éstas identifican las condiciones de inestabilidad hemodinámica como una indicación clase I para realizar EtE, ya que ayuda a establecer la etiología y a guiar la terapia en el transoperatorio. [17][18][19] CoNCLUSIoNES Existen numerosos estudios de monitoreo hemodinámico en la paciente obstétrica con el objetivo de minimizar la morbilidad y mortalidad materna. La monitorización hemodinámica no invasiva parece ganar terreno en los cuidados de pacientes críticos, en especial en pacien-www.medigraphic.org.mx ...
Pregnancy is a state, which poses a real challenge to the maternal cardiovascular system. Obstetric patients who are complicated by preeclampsia, heart disease, sepsis, hemorrhage and pulmonary thromboembolism are characterized by profound hemodynamic alterations, which represent the main causes of morbidity and extreme maternal mortality, so there is a need for a correct evaluation and monitoring of these parameters, which is validated in this type of patients. The objective of this review is to describe the technology available at the patient’s bedside for the performance of this hemodynamic monitoring in the high-risk pregnant patient.
... Tran esophageal echocardiography (TEE) is rarely used in obstetrics, because it very often requires tracheal intubation and can be performed only by an experienced practitioner. However, some authors suggest it as a guide in management of refractory hypotension and cardiac arrest in obstetric patients (38), thus TTE could find its place in very severe forms of PPCM. ...
Peripartum cardiomyopathy (PPCM) is a systolic heart failure that occurs during the last month of pregnancy or within 5 months after delivery. It is an uncommon disease of unknown etiopathogenesis and has a very high rate of maternal mortality. Because of similarity between symptoms of PPCM and physiological discomforts during pregnancy, the early diagnosis of PPCM presents a major challenge. Since hemodynamic changes during PPCM can vitally jeopardize the mother and the fetus, patients with severe forms of PPCM require a multidisciplinary approach in intensive care units. This review summarizes the current state of knowledge about the diagnosis, monitoring, and the treatment of PPCM. Having reviewed the recent researches, it gives insight into the new treatment strategies of this rare disease.
... 10 There were 775 diagnoses identified from these studies. [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. ...
Purpose:
Point-of-care ultrasound (POCU) is an evolving field in anesthesia. Therefore a systematic review of common diagnoses made by POCU during non-cardiac surgery was conducted. The information obtained from the review may be used to develop POCU curricula for the perioperative setting during non-cardiac surgery.
Source:
A systematic review was conducted for perioperative use of transthoracic /transesophageal echocardiography (TTE/TEE) in high-risk patients or in other patients experiencing periods of hemodynamic instability. The diagnoses included segmental wall motion abnormalities (SWMAs), low left ventricular ejection fraction (LVEF), hypovolemia, air embolism, cardiac/aortic thrombus, pulmonary embolus (PE), aortic valve disease, mitral valve disease, tricuspid valve disease, right ventricular (RV) failure, pericardial disease, and patent foramen ovale.
Principal findings:
Three hundred twenty-one studies were found using our search terms, and thirteen studies were retained that met our inclusion criteria for review. The studies included 968 patients analyzed as either preoperative exams in high-risk patients (n = 568) or intraoperative exams during times of hemodynamic compromise/cardiac arrest (n = 400). The most common diagnoses in the preoperative exam group were low ejection fraction (25.4%), aortic valve disease (24.4%), mitral valve disease (20.0%), RV failure (6.6%), and hypovolemia (6.3%). In the intraoperative exam group, the most common diagnoses were hypovolemia (33.2%), low ejection fraction (20.5%), RV failure (13.1%), SWMAs (10.1%), and PE (5.8%).
Conclusion:
In this systematic review examining the use of TTE or TEE in non-cardiac surgery, the most frequent diagnoses were valvulopathy, low LVEF, hypovolemia, PE, SWMAs, and RV failure. This information should be used to inform evidence-based curricula for POCU in anesthesiology.
Introduction
Intra-arrest transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have been introduced in adult patients with cardiac arrest (CA). Whether the diagnostic performance of TTE or TEE is superior during resuscitation is unclear. We conducted a systematic review following PRISMA guidelines.
Methods
We searched databases from PubMed, Embase, and Google Scholar and evaluated articles with intra-arrest TTE and TEE in adult patients with non-traumatic CA. Two authors independently screened and selected articles for inclusion; they then dual-extracted study characteristics and target conditions (pericardial effusion, aortic dissection, pulmonary embolism, myocardial infarction, hypovolemia, left ventricular dysfunction, and sonographic cardiac activity). We performed quality assessment using the Quality Assessment of Diagnostic Accuracy Studies Version 2 criteria.
Results
A total of 27 studies were included: 14 studies with 2,145 patients assessed TTE; and 16 with 556 patients assessed TEE. A high risk of bias or applicability concerns in at least one domain was present in 20 studies (74%). Both TTE and TEE found positive findings in nearly one-half of the patients. The etiology of CA was identified in 13% (271/2,145), and intervention was performed in 38% (102/271) of patients in the TTE group. In patients who received TEE, the etiology was identified in 43% (239/556), and intervention was performed in 28% (68/239). In the TEE group, a higher incidence regarding the etiology of CA was observed, particularly for those with aortic dissection. However, the outcome of those with aortic dissection in the TEE group was poor.
Conclusion
While TEE could identify more causes of CA than TTE, sonographic cardiac activity was reported much more in the TTE group. The impact of TTE and TEE on the return of spontaneous circulation and further survival was still inconclusive in the current dataset.
Background
Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) – lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE.
Methods
MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31 st , 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate.
Results
Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported.
Conclusions
The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.
Women with structural cardiac or coronary artery disease may have an attenuated ability to adapt to the cardiovascular changes associated with pregnancy. The use of cardiopulmonary bypass (CPB) may be necessary and unavoidable for many urgent or emergent cardiac surgical repairs. Accurate maternal and fetal risk assessment prior to surgery is fundamental for preoperative care. CPB may cause significant alterations in patient physiology, with virtually every organ system affected. The main pathophysiological changes that can affect the fetus under CPB are uterine contraction, placental hypoperfusion, and fetal hypoxia. There are three primary aims in the anesthetic management of patients undergoing CPB: providing safe maternal hemodynamic management, avoiding teratogenic agents, and minimizing effects of CPB that may induce premature labor. The application of cardioplegia may need to be more frequent with the maintenance of high flows during CPB, especially if normothermia or only mild hypothermia is employed.
Amniotic fluid embolism is a rare but often catastrophic emergency. The non-specific clinical features and lack of diagnostic tests make it a diagnosis of exclusion. Point-of-care visco-elastometric testing is being increasingly used during obstetric haemorrhage. We present a case of amniotic fluid embolism, diagnosed and managed using rotational thromboelastography. During a precipitous labour, a 21-year-old multiparous woman became pale, distressed and disorientated. The fetus was delivered using forceps. Simultaneously maternal cardiac arrest occurred and advanced life support was commenced. As there was no obvious bleeding, pulmonary embolism was considered the most likely diagnosis and preparation was made to thrombolyse. During resuscitation, rotational thromboelastometry demonstrated haemostatic failure, supporting a diagnosis of amniotic fluid embolism. This reversed the decision to thrombolyse and focused the team on resuscitation and management of coagulopathy. Targeted blood products were given using a local protocol specific to obstetric bleeding. Return of cardiac output was achieved. The total measured blood loss was more than 3.6 L and transfusion was guided by point-of-care tests. Transfused blood products were six units of packed red blood cells, one pool of platelets, 12 units of fresh frozen plasma and 14 g of fibrinogen concentrate. This case demonstrates amniotic fluid embolism with haemostatic failure, without initial revealed blood loss. The high mortality of amniotic fluid embolism necessitates rapid diagnosis and aggressive management. Laboratory tests in this context are impractical in informing clinical decisions, showing the value of point-of-care testing in facilitating team work and timely administration of targeted blood products.
