Does intraoperative transesophageal echocardiography improve diagnosis and management in patients experiencing unexpected intraoperative cardiac arrest during noncardiac surgery?
Intraoperative TEE is highly useful for diagnosing the etiology of unexpected cardiac arrest during noncardiac surgery and frequently alters clinical management.
In Brief According to guidelines established by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists, life-threatening hemodynamic disturbances are classified as a category I indication for the intraoperative use of transesophageal echocardiography (TEE). However, the usefulness of TEE during intraoperative cardiac arrest and its impact on patient management have not been rigorously investigated. Using our departmental TEE database, we identified a population of 22 patients who underwent noncardiac surgical procedures and experienced unexpected intraoperative hemodynamic collapse requiring the initiation of Advanced Cardiac Life Support procedures between the time of induction of general anesthesia and the termination of the surgical procedure. Results of TEE examinations, patient records, detailed operative records, and outcome of patients were reviewed for the utility of TEE to diagnose the etiology of the hemodynamic collapse. Furthermore, the impact on subsequent patient management was evaluated. A primary suspected diagnosis of the underlying pathological process was established in 19 of 22 patients with TEE, including 9 with thromboembolic events, 6 with acute myocardial ischemia, 2 with hypovolemia, and 2 patients with pericardial tamponade. A definitive diagnosis could not be made in 3 patients with TEE. In 18 patients, TEE guided specific management beyond implementation of Advanced Cardiac Life Support protocols, including the addition of surgical procedures in 12 patients. Fourteen patients survived to leave the operating room, and 7 of these patients were eventually discharged from the hospital. Thus, TEE may provide additional diagnostic information in patients with intraoperative cardiac arrest and may directly guide specific, potentially life-saving therapy. IMPLICATIONS: Twenty-two patients experiencing unexpected intraoperative cardiac arrest during noncardiac surgery were evaluated with intraoperative transesophageal echocardiography. Transesophageal echocardiography significantly contributed to determining the etiology of the cardiac arrest in 86% and influenced management in 82% of the patients. Transesophageal echocardiography may be a valuable diagnostic tool when used early during intraoperative cardiac arrest.
Memtsoudis et al. (2006) studied this question.