Development of a Rescue Echocardiography Protocol for Noncardiac Surgery Patients

Genevieve E. Staudt, MD; Kenneth Shelton, MD


Anesth Analg. 2019;129(2):e37-e40. 

In This Article

Abstract and Introduction


Intraoperative transesophageal echocardiography (TEE) is a helpful diagnostic tool when hemodynamic compromise is encountered during noncardiac surgery. At our institution, a Rescue Echo Protocol was created to provide a structured means for requesting and performing a rescue TEE. We analyzed our institutional utilization of this service and found that it was used throughout the spectrum of patients' American Society of Anesthesiologists classifications and surgical services. We demonstrated that 72.9% of rescue examinations resulted in a change in management, supporting the use of TEE as a diagnostic tool during hemodynamic compromise.


The use of intraoperative transesophageal echocardiography (TEE) is recommended for patients undergoing noncardiac surgery who encounter persistent hypotension, hypoxia, or life-threatening hemodynamic compromise.[1–3] However, use of this advanced diagnostic tool may be limited by scarcity of equipment and TEE-trained physicians. At our institution, a Rescue Echo Protocol was created in May 2015 to enable access to TEE services in noncardiac operating rooms. Our approach to create a successful and sustainable program was 3-fold.

First, we created a formal Rescue Echo Service (RES) to provide basic organizational structure. This established provider roles to improve response time and outlined means of communication to minimize confusion surrounding requests for TEE. The RES is covered 24/7 by pager. During the day, the pager is carried by a designated cardiac anesthesia fellow. At night, the pager is carried by the in-house resident on cardiac call. TEE examinations may be performed by cardiac fellows or senior residents but must be supervised by a cardiac attending who is certified in advanced perioperative TEE. The on-call cardiac attending is responsible for overseeing image acquisition and interpretation, as well as finalizing the TEE report in the record. If not physically present when a TEE is requested, they must decide whether to come to the hospital or use an alternative in-house colleague who is often a cardiac attending covering the intensive care unit. This judgment call is made on a case-by-case basis. The RES TEE examinations are performed with a designated Philips iE33 ultrasound machine (Andover, MA). All TEE images were archived, and a formal report was generated.

Next, we developed a modified TEE examination sequence to promote a focused, expeditious examination (Figure). This sequence consists of 5 of the standard views included in both the American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists basic and comprehensive TEE examinations.[1,2] These views were chosen because they are relatively easy to obtain, simple to interpret with some background in TEE, and focus on structures that are most frequently implicated in serious hemodynamic compromise. The purpose of rescue TEE is to swiftly recognize serious cardiac pathology, not undertake a comprehensive echocardiographic evaluation, a goal that is bolstered by using this simple sequence. Validation of this examination sequence is beyond the scope of this study.


Rescue Echo Protocol. TEE diagrams adapted from Reeves et al.1 AV indicates aortic valve; EKG, electrocardiogram; HOCM, hypertrophic obstructive cardiomyopathy; LAX, long axis; ME, midesophageal; PFO, patent foramen ovale; SAM, systolic anterior motion of the mitral valve; SAX, short axis; TEE, transesophageal echocardiography; TG, transgastric.

Finally, to strengthen the educational component of our service, we created a cognitive aid detailing the Rescue Echo Protocol, including the examination sequence detailed earlier, indications, contraindications, and events to exclude (Figure). Included on the back of the aid is additional information regarding diagnosis, TEE findings, clinical correlates, and management options.[4] This cognitive aid is affixed to the machine designated for rescue TEE and is therefore always available when performing a rescue examination.

In this study, we evaluated the use of the RES at our institution over a 22-month period to demonstrate that intraoperative TEE may be used during noncardiac surgery to guide management during hemodynamic instability.