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Echocardiographic Assessment Using Subxiphoid-Only Examination for Hypotensive Patients

Point-of-care ultrasound, or POCUS, has gathered significant interest as a tool to augment clinical decision-making in the care of acutely ill patients. ...

Albany Medical Center

Sepsis and septic shock are medical emergencies, with high associated mortality. The Surviving Sepsis Campaign has developed definitions and management guidelines, emphasizing the use of hour-1 care bundle. Anesthesiologists frequently encounter sepsis when source control is required. The authors summarize expected manifestations of organ dysfunction and state-of-the-art management of patients with sepsis and septic shock. They highlight an increasingly vital role point-of-care ultrasound examination in the recognition and management of hemodynamic derangements in this patient population. Supporting the role of anesthesiologists as perioperative physicians, the authors provide a framework for transitions of care between operating room and intensive care units.

Perioperative Management of Patients with Sepsis and Septic Shock, Part I: Systematic Approach.

Point-of-care ultrasound is capable of identifying the precise causes of hemodynamic failure in patients with septic shock. Patients in shock demonstrate complex alterations in their circulation, including changes in loading conditions (preload and afterload), right and left ventricular function, and development of obstructive physiology, and some of them have a burden of underlying cardiac disease. Knowledge of underlying hemodynamic derangements in such situations allows targeted interventions, that is, fluids, vasoactive, and inotropic medications, to optimize patient's perfusion. One example of competing goals involves a patient with hypertrophic "thick" left ventricle (LV), which is easily identified using point-of-care ultrasound (POCUS). Such patients usually have diastolic dysfunction and commonly require higher filling pressures (mainly grade II and III diastolic dysfunction) to maintain adequate cardiac output. They are vulnerable to the effects of hypovolemia with the potential for dynamic LV outflow tract (LVOT) obstruction. The use of inotrope is harmful under these circumstances and could lead to worsening of the obstructive physiology because of systolic anterior motion of the mitral valve leaflet and mitral regurgitation with rapid progression toward a cardiac arrest. Recognizing the increasingly important role of POCUS in the perioperative arena, in this review, we highlight how POCUS allows anesthesiologists to recognize and manage hemodynamic derangements in patients with sepsis and septic shock. We provide a systematic approach to the evaluation of this patient population using qualitative assessment of myocardial performance, fluid responsiveness, and fluid tolerance. Our approach is based on a limited number of ultrasound views: subcostal, inferior vena cava (IVC), and lung views are obtained in rapid succession. A combination of findings in these views is grouped into distinct hemodynamic phenotypes, each of them requiring their own approach to management.

Perioperative Management of Patients with Sepsis and Septic Shock, Part II: Ultrasound Support for Resuscitation.

When incorporated into the 10-second pulse/rhythm check of the advanced life support (ALS) protocol, focused cardiac ultrasound is a useful adjunct to cardiopulmonary resuscitation. In this case series, we demonstrated the feasibility of echocardiographic assessment using subcostal-only view in ALS (EASy-ALS) performed by anesthesiology residents during the periresuscitative period after structured training. Residents obtained diagnostic quality images in 100% of the self-reported cases, which enabled them to identify cardiac motion and potentially reversible causes of hemodynamic instability. Implementation of EASy-ALS into practice requires system-wide changes in cardiac arrest management for consistency, quality, and further evaluation of patient outcomes.

Focused Cardiac Ultrasound and the Periresuscitative Period: A Case Series of Resident-Performed Echocardiographic Assessment Using Subcostal-Only View in Advanced Life Support.

Surgical aortic valve replacement requires a comprehensive transoesophageal echocardiography (TEE) assessment before and after the intervention by cardiac anaesthesiologists. For patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI), TEE is not routinely used. We started using transthoracic echocardiography (TTE) as a diagnostic and monitoring modality during TF-TAVI procedures. The aim of this study is to examine the usefulness of TTE before and after TF-TAVI. We hypothesised that TTE can serve as a screening tool in TF-TAVI patients and help rule out significant paravalvular leaks (PVLs), and serve as a monitoring tool.

Point-of-Care Ultrasound Before and After Transfemoral Transcatheter Aortic Valve Implantation.

Macrocirculation and Microcirculation in Septic Shock.

To evaluate whether echocardiographic assessment using the subcostal-only window (EASy) compared with focused transthoracic echocardiography (FTTE) using three windows (parasternal, apical, and subcostal) can provide critical information to serve as an entry-point technique for novice sonographers.

Comparison of qualitative information obtained with the echocardiographic assessment using subcostal-only view and focused transthoracic echocardiography examinations: a prospective observational study.

In reply: The value of subcostal echocardiographic assessment and directions for future research.

Barriers to focused cardiac ultrasound training: A survey of anesthesiology program directors.

We assessed the efficacy of 1-day training in echocardiography assessment using subxiphoid-only (EASy) followed by supervised image interpretation and decision-making during patient rounds as a novel approach to scaling up the use of point-of-care ultrasound (POCUS) in critically ill patients.

Is 1 Day of Focused Training in Echocardiographic Assessment Using Subxiphoid-Only (EASy) Examination Enough? A Tertiary Hospital Response to the COVID-19 Crisis and the Use of the EASy Examination to Support Unit-Wide Image Acquisition.

While point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) is broadly perceived as having value in intravascular volume status assessment, this has not been borne out in large-scale meta-analyses containing heterogenous populations of acutely ill patients. While the limitations of IVC POCUS could be largely due to the complexity of the relationship between IVC appearance and volume status, another confounder not widely appreciated is the ease with which the aorta or right hepatic vein (RHV) can be mistaken for the IVC. While misidentification of the aorta as the IVC has been recognized elsewhere, misidentification of the RHV for the IVC has not and, in our experience, occurs frequently, even in the hands of experienced sonographers. We demonstrate how these errors occur and provide guidance on how to systematically avoid them.

Article	Year
Perioperative Management of Patients with Sepsis and Septic Shock, Part I: Systematic Approach. Anesthesiology clinics\| PubMed ID: 32008646	2020
Perioperative Management of Patients with Sepsis and Septic Shock, Part II: Ultrasound Support for Resuscitation. Anesthesiology clinics\| PubMed ID: 32008647	2020
Focused Cardiac Ultrasound and the Periresuscitative Period: A Case Series of Resident-Performed Echocardiographic Assessment Using Subcostal-Only View in Advanced Life Support. A&A practice\| PubMed ID: 32739984	2020
Point-of-Care Ultrasound Before and After Transfemoral Transcatheter Aortic Valve Implantation. Turkish journal of anaesthesiology and reanimation\| PubMed ID: 33313589	2020
Macrocirculation and Microcirculation in Septic Shock. Anesthesia and analgesia\| PubMed ID: 34403395	2021
Comparison of qualitative information obtained with the echocardiographic assessment using subcostal-only view and focused transthoracic echocardiography examinations: a prospective observat... Canadian journal of anaesthesia = Journal canadien d'anesthesie\| PubMed ID: 34796459	2022
In reply: The value of subcostal echocardiographic assessment and directions for future research. Canadian journal of anaesthesia = Journal canadien d'anesthesie\| PubMed ID: 35211873	2022
Barriers to focused cardiac ultrasound training: A survey of anesthesiology program directors. Journal of clinical anesthesia\| PubMed ID: 36528959	2023
Is 1 Day of Focused Training in Echocardiographic Assessment Using Subxiphoid-Only (EASy) Examination Enough? A Tertiary Hospital Response to the COVID-19 Crisis and the Use of the EASy Exam... Critical care explorations\| PubMed ID: 38415022	2024
Mistaken Identity: Misidentification of Other Vascular Structures as the Inferior Vena Cava and How to Avoid It. Diagnostics (Basel, Switzerland)\| PubMed ID: 39410622	2024

Nibras Bughrara

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