- Email: [email protected]
PAUSE: Perioperative Bedside Ultrasound
Author’s Accepted Manuscript PAUSE – Perioperative Bedside Ultrasound Vinayak Desurkar, Rajesh Bhavsar
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1053-0770(16)30136-7 http://dx.doi.org/10.1053/j.jvca.2016.05.014 YJCAN3685
To appear in: Journal of Cardiothoracic and Vascular Anesthesia Cite this article as: Vinayak Desurkar and Rajesh Bhavsar, PAUSE – Perioperative Bedside Ultrasound, Journal of Cardiothoracic and Vascular Anesthesia, http://dx.doi.org/10.1053/j.jvca.2016.05.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Letter to Editor. PAUSE – Perioperative Bedside Ultrasound.
Corresponding Author : Dr Vinayak Desurkar MD, FRCA . Consultant Anaesthesiologist Department of Anaethesia Deenanath Mangeshkar Hospital Pune India 411004 Email: [email protected]
Dr Rajesh Bhavsar Consultant Anaesthesiologist PICEU Foundation Pune India. 411038 Email: [email protected]
To the Editor :
In the article entitled Perioperative Anesthesiology UltraSonographic Evaluation (PAUSE): A Guided Approach to Perioperative Bedside Ultrasound 1, Adam and colleagues have presented a new point of care ultrasonography( POCUS) algorithm with the name of PAUSE which is suitable for perioperative situations and designed specially for general anaesthesiologists. The authors have described structured approach to using bedside ultrasound as a physical examination adjunct and diagnostic tool that can be learned and performed by the general anesthesiologist. These recommendations to providers; new to the use of ultrasound for diagnostic imaging, can prompt them to learn and properly apply these skills. The authors, in their introduction have presented a convincing review of literature, supporting the use of POC US in perioperative haemodynamically unstable situations. We would like to thank the authors for agreeing with (FATE) views, which have been presented in previous articles
(2,3,4,5)
We would like to
mention that, we agree with the author's reasoning of why POC US is necessary and how it can be useful in perioperative situations. It is very interesting to see the implementation of echo views described in the FATE protocol in different sequence with different perspective. Here again we again would like to thank the authors to support the utility of these views. However in the introductory paragraph, it is mentioned that “However, these approaches (e.g. FATE) exclude scanning of the lungs/pleura for pulmonary pathologic conditions, which may be important, especially during or after the administration of anesthesia.”
We would like to mention that lung scanning has always been an integral part of FATE protocol
2,6
as pneumothorax and pleural effusion are frequent contributory
factors for cardiorespiratory instability and must be scanned in haemodynamically compromised situations. Position 4 in the FATE protocol demonstrates presence or absence pleural sliding and pleural effusion. Localisation of lung point, i.e. the point where lung sliding starts, may help in demarketing of the extent of pneumothorax. Hyperechoic shadows at the basal lung fields may suggest atelectasis and indicate need for PEEP or recruitment. Hyperechoic linear shadows in the lung scan called B lines indicate interstitial fluid. Increased numbers of these B lines indicate pulmonary oedema. Further in the article, in the description of intra/postoperative evaluation of the haemodynamic instability with POC US; authors have mentioned that, when pulmonary embolism is suspected IVC view( for demonstration of venous stasis by visualising distended IVC) and parasternal pulmonary artery bifurcation views should be included. Supporting to the authors point, we would like to add that the parasternal (short) axis view should be an integral part of evaluation for pulmonary embolism as it shows both ventricles and interventricular septum. Interventricular septum position i.e. ventricular interdependency 2, during acute right ventricular failure may be helpful in supporting the diagnosis of acute pulmonary embolism. Similarly we would also like to suggest that TAPSE (tricuspid annular plane systolic excursion) calculation should be an important part in preoperative evaluation as it may be helpful in diagnosing and monitoring of right ventricular function in acute right ventricular failure. We would further like to state that TAPSE calculation should be an obligatory part of the basic echocardiography training.
Having said that FATE protocol is practiced in various parts of the world for Intensive care and emergency situations, PAUSE is a commendable effort for general anaesthesiologist community.
References: 1.
Adam C. Adler, William J. Greeley, Frederick Conlin, Jeffrey M. Feldman :
Perioperative Anesthesiology UltraSonographic Evaluation (PAUSE): A Guided Approach to Perioperative Bedside Ultrasound. J Cardiothorac Vasc Anesth. 2016;30:521–529 2.
Jensen MB, Sloth E, Larsen KM, et al: Transthoracic echocardiography for
cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol 21:700-707, 2004 3.
Jimmy Højberg Holm, Christian Alcaraz Frederiksen, Peter Juhl-Olsen, and
Erik Sloth. Perioperative Use of Focus Assessed Transthoracic Echocardiography (FATE). Anesth Analg. 115(5):1029-1032, November 2012. 4.
Frederiksen CA, Juhl-Olsen P, Larsen UT, Nielsen DG, Eika B, Sloth E. New
pocket echocardiography device is interchangeable with high-end portable system when performed by experienced examiners. Acta Anaesthesiol Scand 2010;54:1217– 23 4. 5.
Jakobsen CJ, Torp P, Sloth E. Perioperative feasibility of imaging the heart
and pleura in patients with aortic stenosis undergoing aortic valve replacement. Eur J Anaesthesiol 2007;24:589–95 6.
Frederiksen CA, Knudsen L, Juhl-Olsen P, Sloth E. Focus assessed
transthoracic echocardiography in the sitting position: two life-saving cases. Acta Anaesthesiol Scand 2011;55:126–9
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1053-0770(16)30136-7 http://dx.doi.org/10.1053/j.jvca.2016.05.014 YJCAN3685
To appear in: Journal of Cardiothoracic and Vascular Anesthesia Cite this article as: Vinayak Desurkar and Rajesh Bhavsar, PAUSE – Perioperative Bedside Ultrasound, Journal of Cardiothoracic and Vascular Anesthesia, http://dx.doi.org/10.1053/j.jvca.2016.05.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Letter to Editor. PAUSE – Perioperative Bedside Ultrasound.
Corresponding Author : Dr Vinayak Desurkar MD, FRCA . Consultant Anaesthesiologist Department of Anaethesia Deenanath Mangeshkar Hospital Pune India 411004 Email: [email protected]
Dr Rajesh Bhavsar Consultant Anaesthesiologist PICEU Foundation Pune India. 411038 Email: [email protected]
To the Editor :
In the article entitled Perioperative Anesthesiology UltraSonographic Evaluation (PAUSE): A Guided Approach to Perioperative Bedside Ultrasound 1, Adam and colleagues have presented a new point of care ultrasonography( POCUS) algorithm with the name of PAUSE which is suitable for perioperative situations and designed specially for general anaesthesiologists. The authors have described structured approach to using bedside ultrasound as a physical examination adjunct and diagnostic tool that can be learned and performed by the general anesthesiologist. These recommendations to providers; new to the use of ultrasound for diagnostic imaging, can prompt them to learn and properly apply these skills. The authors, in their introduction have presented a convincing review of literature, supporting the use of POC US in perioperative haemodynamically unstable situations. We would like to thank the authors for agreeing with (FATE) views, which have been presented in previous articles
(2,3,4,5)
We would like to
mention that, we agree with the author's reasoning of why POC US is necessary and how it can be useful in perioperative situations. It is very interesting to see the implementation of echo views described in the FATE protocol in different sequence with different perspective. Here again we again would like to thank the authors to support the utility of these views. However in the introductory paragraph, it is mentioned that “However, these approaches (e.g. FATE) exclude scanning of the lungs/pleura for pulmonary pathologic conditions, which may be important, especially during or after the administration of anesthesia.”
We would like to mention that lung scanning has always been an integral part of FATE protocol
2,6
as pneumothorax and pleural effusion are frequent contributory
factors for cardiorespiratory instability and must be scanned in haemodynamically compromised situations. Position 4 in the FATE protocol demonstrates presence or absence pleural sliding and pleural effusion. Localisation of lung point, i.e. the point where lung sliding starts, may help in demarketing of the extent of pneumothorax. Hyperechoic shadows at the basal lung fields may suggest atelectasis and indicate need for PEEP or recruitment. Hyperechoic linear shadows in the lung scan called B lines indicate interstitial fluid. Increased numbers of these B lines indicate pulmonary oedema. Further in the article, in the description of intra/postoperative evaluation of the haemodynamic instability with POC US; authors have mentioned that, when pulmonary embolism is suspected IVC view( for demonstration of venous stasis by visualising distended IVC) and parasternal pulmonary artery bifurcation views should be included. Supporting to the authors point, we would like to add that the parasternal (short) axis view should be an integral part of evaluation for pulmonary embolism as it shows both ventricles and interventricular septum. Interventricular septum position i.e. ventricular interdependency 2, during acute right ventricular failure may be helpful in supporting the diagnosis of acute pulmonary embolism. Similarly we would also like to suggest that TAPSE (tricuspid annular plane systolic excursion) calculation should be an important part in preoperative evaluation as it may be helpful in diagnosing and monitoring of right ventricular function in acute right ventricular failure. We would further like to state that TAPSE calculation should be an obligatory part of the basic echocardiography training.
Having said that FATE protocol is practiced in various parts of the world for Intensive care and emergency situations, PAUSE is a commendable effort for general anaesthesiologist community.
References: 1.
Adam C. Adler, William J. Greeley, Frederick Conlin, Jeffrey M. Feldman :
Perioperative Anesthesiology UltraSonographic Evaluation (PAUSE): A Guided Approach to Perioperative Bedside Ultrasound. J Cardiothorac Vasc Anesth. 2016;30:521–529 2.
Jensen MB, Sloth E, Larsen KM, et al: Transthoracic echocardiography for
cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol 21:700-707, 2004 3.
Jimmy Højberg Holm, Christian Alcaraz Frederiksen, Peter Juhl-Olsen, and
Erik Sloth. Perioperative Use of Focus Assessed Transthoracic Echocardiography (FATE). Anesth Analg. 115(5):1029-1032, November 2012. 4.
Frederiksen CA, Juhl-Olsen P, Larsen UT, Nielsen DG, Eika B, Sloth E. New
pocket echocardiography device is interchangeable with high-end portable system when performed by experienced examiners. Acta Anaesthesiol Scand 2010;54:1217– 23 4. 5.
Jakobsen CJ, Torp P, Sloth E. Perioperative feasibility of imaging the heart
and pleura in patients with aortic stenosis undergoing aortic valve replacement. Eur J Anaesthesiol 2007;24:589–95 6.
Frederiksen CA, Knudsen L, Juhl-Olsen P, Sloth E. Focus assessed
transthoracic echocardiography in the sitting position: two life-saving cases. Acta Anaesthesiol Scand 2011;55:126–9