January 1, 2014
Volume 78, Number 1
What’s New In ... Perioperative Ultrasound: Followers or Leaders?
John Rotruck, M.D.
Committee on Cardiovascular and Thoracic Anesthesia
Aparna Ananth, M.D.
Committee on Cardiovascular and Thoracic Anesthesia
No reader of this NEWSLETTER likely needs much convincing about the clinical utility of ultrasound competency for us, as anesthesiologists and perioperative physicians. The growing list of indications and uses of clinical ultrasound in the perioperative and critical care arenas makes this a skill that is no longer discretionary for anesthesiologists. Live ultrasound guidance is becoming ever more prevalent for the placement of regional nerve blocks, supplanting nerve stimulation techniques at many centers. Ultrasound is also gaining in importance for placement of neuraxial blocks, especially in challenging patients. Some time ago, anesthesiologists began using this technology to visualize the vascular anatomy prior to central venous cannulation, and now an ever-increasing number of practitioners are placing internal jugular and subclavian catheters with live ultrasound guidance. The latter practice is now recommended in guidelines endorsed by the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.1
A more specialized use of ultrasound comes in the form of transesophageal echocardiography (TEE), long used by anesthesiologists as both a monitor and a diagnostic tool during cardiac surgery. TEE is no longer limited to the realm of the cardiac anesthesiologist, however, as it is seeing increasing application in non-cardiac cases. TEE is now being used as a monitoring modality in noncardiac surgery in the hands of anesthesiologists who either don’t have fellowship training or extensive practical experience; TEE is likewise seeing increasing use in perioperative management in the critical care arena, whether in the form of a traditional multiplane probe or a narrow diameter single plane probe, otherwise known as “hemodynamic TEE.” A small subset of anesthesiologists have even achieved competency in the use of transthoracic echocardiography (TTE) for the preoperative evaluation of structural heart disease, as well as the intra- and postoperative evaluation of hemodynamic compromise. Another growing application in the critical care arena is lung ultrasound for diagnosis of pleural effusion, alveolar disease and pneumothorax.
All that being said, the only consistent thing we have achieved as a specialty is inconsistency with respect to clinical ultrasound. This inconsistency extends from the way we train our residents to the way we practice as staff anesthesiologists. This is not an optimal situation for a specialty that emphasizes standardization as a pathway to patient safety and quality care. Our colleagues in emergency medicine and critical care are way ahead of us in terms of standardizing the requirements for house staff training in the use of ultrasound.2,3 Although the National Board of Echocardiography (NBE) has established the requirements for certification in Basic Perioperative TEE, that core curriculum or any part thereof that would lead to clinical competence has not become a part of our core residency training requirements, beyond a statement that residents should have “significant experience” with TEE.4 At the present time, there is no other mention of ultrasound use in the core ACGME program requirements.
Do we want our anesthesiology trainees to be proficient in central venous access under live ultrasound guidance? Do we want them to be able to apply an ultrasound probe to the chest wall and look for evidence of a pneumothorax, or to get a general sense of cardiac filling and function and be able to monitor that over time? Do we ultimately want our graduates to have met all the experience requirements for NBE Basic Perioperative TEE certification? Individual residency programs may have answered those questions to varying degrees, but as a specialty we have not. Moreover, how will we offer and document training for this type of education to anesthesiologists already in practice? It is imperative that we answer these and related questions now. If we wish to be true perioperative physicians and potentially the managers of a perioperative surgical home, demonstrated clinical competence in a wide range of ultrasound applications will be critical.
In summary, the phenomenal growth of the use of various ultrasound modalities in the perioperative and critical care arenas makes it crucially important for anesthesiologists to familiarize themselves with this technology and its applications. At the end of the day, when it comes to the clinical use of ultrasound in our practice as anesthesiologists – and the way we train our residents and fellows to do the same – do we want to be followers or leaders?
John Rotruck, M.D. is Chief of Cardiothoracic Anesthesiology and the President of the Medical Staff at a tertiary care academic medical center in the Washington, D.C. Metro area.
Aparna Ananth, M.D. is an anesthesiologist in private practice with Pacific Anesthesia, PC, St. Joseph Medical Center, Tacoma, Washington.
1. Troianos CA, Hartman GS, Glas KE, et al.; Councils on Intraoperative Echocardiography and Vascular Ultrasound of the American Society of Echocardiography. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2011;24(12):1291-1318.
2. American College of Emergency Physicians. Policy statement: emergency ultrasound guidelines. http://www.acep.org/policystatements/. Approved October, 2008. Accessed November 15, 2013.
3. Expert Round Table on Ultrasound in ICU. International expert statement on training standards for critical care ultrasonography. Intensive Care Med. 2011;37(7): 1077-1083.
4. ACGME program requirements for graduate medical education in anesthesiology. Chicago, IL: Accreditation Council for Graduate Medical Education; July 1, 2011.