Echocardiographic assessment by anaesthetists

We read with interest the article by Loxdale et al. [1]. In unselected patients with a hip fracture, they found that 8% of patients have moderate or severe aortic stenosis and that 7% have moderate or severe impairment of left ventricular function. Moreover, they found that detection of a murmur does not predict the presence of valvular disease and that patients could have valvular disease without a murmur detected. Therefore, a pre-operative echocardiogram appears necessary before anaesthesia in this elderly population and the results may have significant implications for subsequent anaesthetic management [2]. Nevertheless, obtaining an echocardiogram may be difficult and the delay between hip fracture and surgery may negatively affect patient outcome [3]. Anaesthetists use ultrasonography to guide peripheral nerve blockade or central venous catheter insertion. They should probably learn to perform bedside echocardiograghy; they have learnt to detect murmurs with a stethoscope. Transthoracic echocardiography may complete the patients’ examination and it could reduce the waiting time before surgery in many cases. After brief formal training, intensivists can successfully perform and correctly interpret a limited transthoracic echocardiography examination in critically ill patients [4]. In our unit, some anaesthetists have learnt to perform echocardiography; they may not be as skilled as cardiologists but assessment of ejection fraction and detection of aortic stenosis is a reasonable goal. Finally, continuous spinal anaesthesia may be an interesting alternative, when a full cardiac examination with transthoracic echocardiography cannot be performed. Titrated bupivacaine injected through an intrathecal catheter provides more hemodynamic stability than a ‘single-shot’ spinal anaesthetic [5]. This technique is safe and effective in patients with valvular heart disease [6].