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


Over the study period, we performed 48 intraoperative rescue TEEs. In the first 11 months, 14 examinations were performed. This number increased to 34 examinations over the next 11 months as awareness of the RES increased. Rescue TEE was used more frequently but not exclusively in older patients (69% of patients >60 years of age).

There was wide range of ASA classifications; however, the majority of patients was ASA III (23/48). A wide variety of surgical services were represented. Orthopedic surgery and neurosurgery each accounted for 14.5% (7/48) of examinations, followed by vascular surgery at 12.5% (6/48). Surgical subspecialties that are generally considered to perform low-risk procedures, such as breast surgery and endocrine surgery, were also represented. This observational study was not powered to make conclusive statements about the acuity of 1 patient population versus another.

The most common indication for rescue TEE was refractory hypotension (47.9%). This was followed by cardiac arrest (22.9%) and ST changes (10.4%). Arrhythmias and hypoxia made up a significantly smaller proportion of requests (Table). In some instances, patients were demonstrating multiple signs of hemodynamic instability (ie, ST changes and refractory hypotension).

TEE findings were classified into 10 categories. Some studies revealed >1 finding, with accounts for a count of >48 studies and an additive percentage of >100% (Table). A normal examination demonstrated absence of any major pathology or displayed a previously known abnormality. This was the most common conclusion, seen in 23 of 48 studies (47.5%). Hypovolemia was diagnosed by visualizing a small, hyperdynamic ventricle with inadequate diastolic filling and low estimated cardiac output, seen in 10 of 48 examinations (20.8%). Valvular abnormalities were only included if they demonstrated at least moderate to severe pathology. Trivial regurgitation was frequently seen but was included in the normal examination group because this physiological finding has little potential to be the cause of hemodynamic instability. Within the valvular disease group, regurgitation was a significantly more common finding than stenosis. Ventricular failure could be left or right sided and included both acute failure and previously unknown chronic failure. Diagnosis of myocardial ischemia required the presence of regional wall motion abnormalities. Pulmonary embolism was only diagnosed if a thrombus was directly visualized in the right ventricular outflow tract or pulmonary artery.

The patients (72.9%) had a change in management after rescue TEE, and some had multiple interventions (Table). Significant interventions included emergent pulmonary thromboendarterectomy, initiation of extracorporeal membrane oxygenation, and case cancellation. It is also important to note that 47.5% of patients had a normal examination; however, only 27.1% had no change in management. This finding suggests that a negative examination may also be helpful in guiding management.

Because this retrospective study is without a control group, we cannot assert that changes in management were made based on rescue TEE findings alone. An additional limitation is the inability to capture whether a change in management such as case continuation was made possible by a normal examination that excluded pathology or reassured providers. Additionally, our study is limited to examinations that included formal TEE report generation. Focused cardiac ultrasound (FoCUS) examinations performed as an extension of the physical examination would be missed with our data collection process.