TRANSESOPHAGEAL%20ECHOCARDIOGRAPHY%20GOAL%20DIRECTED%20FLUID%20THERAPY%20DURING%20ANESTHESIA

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TRANSESOPHAGEAL ECHOCARDIOGRAPHYGOAL DIRECTED
FLUID THERAPY DURING ANESTHESIA
Dr Piyush Mallick MD Consulatnt Anesthesia ICU
Al Zahra Hospital Sharjah
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INTRODUCTION

• In 1976, Dr Leon Frazin - concept of TEE.
• Echocardiography- the heart and great vessels
  probed with ultrasound (sound with frequency
  above 20 kHz).
• Echocardiography uses ultrasound waves with
  frequency of 2.5 7.5 MHz.
• Ultrasound sent into thoracic cavity and
  partially reflected by cardiac structures.
• From these reflections distance, velocity and
  density of objects within the chest derived.

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INDICATIONS FOR PERIOPERATIVE TEE

• Preoperative hemodynamically unstable patients
  with no definite diagnosis like suspected
  thoracic aortic aneurysms, dissection, or
  undifferentiated shock state
• Intraoperative
• acute, persistent, and life-threatening
  hemodynamic disturbances
• valve repair, CHD surgery for lesions requiring
  cardiopulmonary bypass repair of hypertrophic
  obstructive cardiomyopathy endocarditis repair
  of aortic dissections pericardial window
  procedures.

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INDICATIONS FOR PERIOPERATIVE TEE

• In ICU unstable patients with unexplained
  hemodynamic disturbances, suspected valve
  disease, or thromboembolic problems.
• TEE guided CPR in ED cardiac arrest ( Both for
  diagnosis Monitoring whether effective CPR)

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TEE.
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TEE EQUIPMENT

• Monitor and TEE probe
• TEE probe a minaturized echocardiographic
  transducer (40mm long, 13mm wide and 11 mm thick)
  mounted on the tip of a gastroscpoe.
• Transducer a phased array configuration with 64
  piezoelectric elements operating at 3.7 to 7.5
  MHz.
• 2 knobs one controls anteflexion and
  retroflexion other controls rightward and
  leftward movement of the probe.
• One electronic switch to scan the heart in
  various axial views .

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PROCEDURE

• Induction of anaesthesia and tracheal intubation
• Patients neck extended
• Well lubricated TEE probe introduced into the
  midline of hypopharynx with transducer facing
  anteriorly
• Probe advanced into esophagus
• During this manoeuvre, the control knob must be
  in neutral position.

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Terminology used to describe transesophageal
echocardiography probe movements.  
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MULTIPLANE PROBE
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I III II
I- UPPER ESOPHAGEAL II- MID ESOPHAGEAL III-
TRANSGASTRIC
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Transesophageal echocardiography cross sections
in a comprehensive examination.
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WHAT ANESTHESIOLOGIST SHOULD KNOW ?

• EVALUATION OF LV FILLING
• TEE reveals changes in left ventricular preload
  and filling pressure.
• It measures EDA (end diastolic volume).
  EDA lt 12cm2 - hypovolemia
• Assessment of LV filling and function
  subjectively with the trained eye a valid
  method to guide fluid administration.

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CARDIAC OUT PUT WITH EACH BEAT

• 2. ESTIMATION OF CARDIAC OUTPUT
• Real-time TEE images of LV filling and ejection
  permits qualitative, immediate detection of
  extreme changes in cardiac output.
• TEE quantify CO the velocity and the
  cross-sectional area of blood flow.
• SV v x ET x CSA
  
  SV
  stroke volume (ml)
  v
  spatial average velocity of blood flow (cm/sec)
  ET systolic ejection time
  (sec)
  CSA cross-sectional area of the vessel (cm2
  )

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SYSTOLIC DIASTOLIC FUNCTION

• 3. Assessment of ventricular systolic function
• Fractional area change (FAC) during systole a
  measure of global LV function.
• FAC EDA ESA / EDA
• EDA cross-sectional area at end diastole
• ESA cross-sectional area at end systole.
• Marked changes in FAC are apparent by simply
  viewing the real-time images.
• Hallmarks of severe RV dysfunction severe
  hypokinesis , enlargement of RV , change in shape
  of RV from crescent to round.

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DIASTOLOGY FOR HFPEF

• 4. Assessment of ventricular diastolic function
• TEE is an ideal tool for assessment of diastolic
  function because of its unobstructed view of the
  mitral valve and pulmonary veins.
• Normal flow across the mitral valve in diastole
  has
• E wave an early higher-velocity component
  (generated by atrial pressure and ventricular
  relaxation)
• A wave lower-velocity component (generated by
  atrial contraction)
• At slower heart rates, these two waves are
  separated by a period of relatively little flow
  (diastasis).

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TAPSE S prime for RV function

• Video

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Line drawings representing simultaneous
transesophageal pulsed wave Doppler recordings
from the mitral annulus and right upper pulmonary
vein.
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HOW MUCH FLUID ?HOW MUCH IS TOO MUCH ?WHEN TO
STOP?

• 1.Based on mitral valve study
• 2.Using E/A wave ratio
• 3. Tissue Doppler e/a ratio

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WHAT HAPPENES IN MYOCARDIAL ISCHEMIA?

• 5. Detection of myocardial ischemia
• Acute myocardial ischaemia produce abnormal
  inward motion and thickening of affected
  myocardium.
• Short axis view of LV at level of papillary
  muscle best view
• Wall thickening more specific marker than wall
  motion.

CLASS OF MOTION CHANGE IN RADIUS
NORMAL gt30 decreased
MILD HYPOKINESIS 10 30 decreased
SEVERE HYPOKINESIS 0 10 decreased
AKINESIS None
DYSKINESIS Increased
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SVC COLLAPSIBILITY AND FLUID RESPONSIVENESS

• 20 TO 30 COLLAPSIBILTY

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ME bicaval
IAS
LA
IVC
SVC
Eustachian valve
Left Atrium (LA) Right Atrium (RA) Inferior Vena
Cava (IVC) Superior Vena Cava (SVC) Intra atrial
septum (IAS)
Right Atrial Appendage
Fossa Ovalis
RA
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CAN WE SEE PULMONARY EMBOLISIM ( BLOOD
CLOT/GAS/AMNIOTIC FLUID)

• RV bigger than LV
• D shaped LV
• McConnel sign
• You can really see the clot

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ME asc aortic SAX
Rt PA
SVC
PA
Asc
Pulmonary Artery (PA) Right Pulmonary Artery (Rt
PA) Superior Vena Cava (SVC) Ascending Aorta (Asc)
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ME asc aortic LAX
Orientation
Ascending Aorta (Asc) Right Pulmonary Artery (Rt
PA)
Rt PA
Asc
Distal
Proximal
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IMAGING TECHNIQUES

• M MODE
• One-dimensional views of cardiac structures
  produced by single-crystal transducers .
• Density and position of all tissues in the path
  of a narrow ultrasound beam displayed as a scroll
  .
• It is a timed motion display.
• Principally used to view rapidly moving
  structures eg. valve leaflets.
• Disadvantages orientation and interpretation of
  spatial relationships difficult.

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M-mode transesophageal echocardiogram of a normal
aortic valve
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IMAGING TECHNIQUES

• 2D MODE
• Rapid, repetitive scanning along many different
  radii within an area in the shape of a fan
  (sector).
• A live (real time image) of heart is produced.
• Advantage the image obtained resembles an
  anatomic section and can be easily interpreted.

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• two-dimensional cross section of a normal aortic
  valve (AV)..

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IMAGING TECHNIQUES

• DOPPLER TECHNIQUE-
• Based on doppler principle.
• With doppler, blood flow velocity can be
  measured.
• Different types of Doppler techniques
• Pulsed wave doppler
• Continuous wave doppler
• Colour flow doppler

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BART

• BLUE AWAY
• RED TOWARDS

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Different types of doppler technique

• TISSUE DOPPLER
• A new use of PWD technology
• To measure myocardial velocity.
• It measures the velocity of the descent of the
  mitral annulus (Sm) towards the apex of the heart
  during normal LV contraction.
• It decreases in presence of myocardial ischemia.

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LA PRESSURE ESTIMATION

• PCWP not needed for LA pressure estimation
• Pulse wave doppler / Tissue doppler
• Can diagnose impending Pulmonary Edema

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ADVANTAGES OF TEE
Transducer 2-3 mm from heart high resolution image better image quality
Closer to posterior structures better visualization of LA,MV, LV, PV, Aorta etc.
Far from surgical field intraoperative monitoring
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DISADVANTAGES OF TEE

• Semi invasive procedure chances of injury
• Needs special set up, technique, preparation,
  instrumentation
• Needs orientation and expertise

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CONTRAINDICATIONS OF TEE

• ABSOLUTE
• Previous esophagectomy
• Severe esophageal obstruction
• Esophageal perforation
• Ongoing esophageal haemorrhage
• RELATIVE
• Esophageal diseases-diverticulum, varices,
  fistula
• Previous esophageal surgery
• Previous mediastinal irradiation
• Unexplained swallowing difficulty

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COMPLICATIONS OF TEE

• Oral and pharyngeal injuries (0.1 0.3)
• Transient hoarseness (0.1 12)
• Esophageal injuries
• Splenic injuries 2 case reports
• Endocarditis in outpatients

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THANK YOU