With this issue of the Anesthesia & Analgesia we are pleased to inaugurate a new format for basic and advanced echo education, Echo Didactics.1 This format continues our efforts to provide the highest-quality venue for education and presentation of clinical research in perioperative echocardiography to our readers, utilizing the formidable intellectual firepower and peer-reviewing skills of internationally renowned echo experts in the Society of Cardiovascular Anesthesiologists and the International Anesthesia Research Society.
Echo Didactics are a logical extension of our Echo Rounds. Echo Rounds have evolved substantially in scope and sophistication since we introduced them in 2005.2 Echo Rounds are case-based presentations of echo didactics, with bulleted “Clinicians Key Teaching Points” summarized by designated editors. Echo Rounds highlight a wide range of echocardiographic techniques and differential diagnosis of cardiac (and occasionally noncardiac) pathology. Echo Rounds provide an excellent venue for highly motivated residents, cardiac anesthesia fellows, faculty, and other practitioners to present interesting echo observations. They have also provided a forum for fellows and junior faculty to learn proper techniques for preparing peer-reviewed publications.
The Echo Rounds database now includes over 150 cases, available on the Society of Cardiovascular Anesthesiologists website (http://www.scahq.org/sca3/rounds/). This database allows our readers to find articles using full text searching and download the PDF of the report and associated video clips and PUBMED links. We expect this venue to be increasingly popular with the introduction of new imaging technology, including “real-time” 3-dimensional imaging, continuous intensive care unit monitoring using smaller disposable transesophageal echocardiography (TEE) probes, advanced nonimaging modalities such as tissue Doppler imaging, speckle tracking, stress strain relations, and focused precordial imaging protocols.3–8 Our greatest resource remains our extensive network of interested clinical practitioners actively using and evaluating novel imaging technologies.
Echo Didactics provides an additional venue in Anesthesia & Analgesia for echo education. It was developed, in part, to provide didactic material appropriate for the Basic TEE certification program of the National Board of Echocardiography as well as their challenging Advanced Perioperative TEE certification pathway.a Mandatory education in the safe and effective use of ultrasound technologies is no longer just a requirement for radiology and cardiology subspecialists, but is required by multiple specialties from obstetrics—in which proper consideration of safety aspects of ultrasound on the developing fetus is crucial—to intensive care and emergency room physicians— in which rapid diagnosis of life-threatening acute pathology is the current standard of care.8,9 Within our own specialty there is recent intense interest in the use of ultrasound for performing regional blocks safely and efficiently establishing central venous and arterial access, elucidating causes for cardiopulmonary arrest and guiding resuscitation, and even for measuring the volume of gastric contents (which may ultimately influence clinical management related to minimizing risks of aspiration on induction).10–14 No doubt other innovative uses will continue to appear. As discussed recently in the New England Journal of Medicine, echo education is no longer the purview of subspecialty journals.15,16
The Society of Cardiovascular Anesthesiologists has been a leader in the development of high-quality echo training programs, and has pioneered development of advanced perioperative TEE certification.17,18 The very recent introduction of the Basic TEE certification pathway is a welcomed response by the National Board of Echocardiography to ensure that TEE and other ultrasound cardiovascular imaging techniques (e.g., surface imaging for central venous access) is performed in the safest and most effective manner. The content outline for this program includes 11 categories (Table 1). Echo Didactics in upcoming issues of the Journal will cover every category. Echo Didactics will not describe actual patient cases, but will offer short “representative” case vignettes used to introduce the topic. Each Echo Didactics report will present a focused discussion of these and other advanced topics to assist our readers in attainting either basic or advanced TEE certification. Echo Didactics will also cover ancillary topics such as transthoracic, epicardial, and epiaortic imaging. Similar to Echo Rounds, Echo Didactics will use a concise format, and incorporate generous amounts of high-quality video and graphics. Submissions to Echo Didactics will undergo rigorous expert peer review to ensure that the information presented is up to date, state of the art, and most important, easily grasped by readers.
Enthusiastic and overly zealous authors often attribute near-magical qualities to TEE probes, stating that “TEE was instrumental in management of this case,” as if the probe is capable of directing itself, and always provides crystal clear images at any depth. Seasoned clinicians know that this is wishful thinking. Only by learning (and continually relearning) the basics, subtleties, and new developments in ultrasound technology and imaging can a clinician extract important information to guide patient management. As pointed out in a recent publication assessing the utility of hand-held ultrasound devices, an experienced echocardiographer using a limited-capability echo system is potentially a better diagnostician than is an inexperienced one using a top-of-the-line echo system.19 This observation is all the more timely given the dazzling cost of some of the newer echo technologies while our health care system is in dire financial trouble. Technical advances in echo are always “cool” but rarely, if ever, make the device easier to use. Most advances add layers of complexity, requiring commensurately more training for the clinician. Our goal in Echo Didactics is to “stick to the basics” and “tell it like it really is.” We think this strategy will advance the perioperative cardiovascular utility of this exciting imaging technology in a way that is both practical and affordable.
We are particularly proud to introduce this series with a concise expert discussion of proper techniques for evaluating the placement of the commonly used intra-aortic balloon pump by Drs. Klopman, Chen, and Sniecinski at Emory University.1 The interactions of a cardiac anesthesia fellow, cardiac surgeon, and a cardiac anesthesiologist (Dr. Sniecinski, a stalwart of the Echo Rounds section and Associate Editor of the A&A Editorial Board) have produced a jewel of a presentation. This introductory Echo Didactics sets a high bar on “how to do it,” both in terms of the echo content, and also how we envisioned Echo Didactics to appear in print. We congratulate this expert team, and look forward to many more to come!
Echo Didactics is currently an invited format, based on known expertise of solicited contributors and, importantly, to avoid duplicative efforts. We are open to inquiries from readers interested in contributing. We also welcome suggestions regarding the format itself.
Ultrasonic imaging is becoming a ubiquitous part of the daily life of the anesthesiologist. We intend our Echo Didactics to provide every clinician with the fundamental knowledge to use echo technology to its full potential when ultrasonic imaging capability is built into every anesthesia workstation.
a Available at: http://www.echoboards.org/. Accessed March 19, 2011.
1. Klopman MA, Chen EP, Sniecinski RM. Positioning an intra-aortic balloon pump using intraoperative transesophageal echocardiogram guidance. Anesth Analg 2011;113:40–3
2. London MJ, Skubas N. Echo Rounds in evolution. Anesth Analg 2007;105:16–8
3. Vegas A, Meineri M. Core review: three-dimensional transesophageal echocardiography is a major advance for intraoperative clinical management of patients undergoing cardiac surgery: a core review. Anesth Analg 2010;110:1538–73
4. Mackensen GB, Swaminathan M, Mathew JP. PRO editorial: PRO: three-dimensional transesophageal echocardiography is a major advance for intraoperative clinical management of patients undergoing cardiac surgery. Anesth Analg 2010;110:1574–8
5. D'Ambra MN. CON editorial: CON: three-dimensional transesophageal echocardiography is a major advance for intraoperative clinical management of patients undergoing cardiac surgery. Anesth Analg 2010;110:1579–80
6. Skubas N. Intraoperative Doppler tissue imaging is a valuable addition to cardiac anesthesiologists' armamentarium: a core review. Anesth Analg 2009;108:48–66
7. Tousignant C. CON: intraoperative Doppler tissue imaging is a valuable addition to cardiac anesthesiologists' armamentarium. Anesth Analg 2009;108:41–7
8. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr 2010;23:1225–30
9. Houston LE, Allsworth J, Macones GA. Ultrasound is safe. Right? Resident and maternal–fetal medicine fellow knowledge regarding obstetric ultrasound safety. J Ultrasound Med 2011;30:21–7
10. Neal JM, Brull R, Chan VW, Grant SA, Horn JL, Liu SS, McCartney CJ, Narouze SN, Perlas A, Salinas FV, Sites BD, Tsui BC. The ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine: executive summary. Reg Anesth Pain Med 2010;35:S1–9
11. Milling TJ Jr, Rose J, Briggs WM, Birkhahn R, Gaeta TJ, Bove JJ, Melniker LA. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) trial. Crit Care Med 2005;33:1764–9
12. Shiloh AL, Savel RH, Paulin LM, Eisen LA. Ultrasound-guided catheterization of the radial artery: a systematic review and meta-analysis of randomized controlled trials. Chest 2011;139:524–9
13. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010;112:1084–96
14. Bouvet L, Mazoit JX, Chassard D, Allaouchiche B, Boselli E, Benhamou D. Clinical assessment of the ultrasonographic measurement of antral area for estimating preoperative gastric content and volume. Anesthesiology 2011;114:1086–92
15. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011;364:749–57
16. Ortega R, Song M, Hansen CJ, Barash P. Videos in clinical medicine. Ultrasound-guided internal jugular vein cannulation. N Engl J Med 2010;362:e57
17. Cahalan MK, Stewart W, Pearlman A, Goldman M, Sears-Rogan P, Abel M, Russell I, Shanewise J, Troianos C. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. J Am Soc Echocardiogr 2002;15:647–52
18. Thys DM. Cardiac anesthesia: thirty years later—the second annual Arthur E. Weyman lecture. Anesth Analg 2009;109:1782–90
19. Prinz C, Voigt JU. Diagnostic accuracy of a hand-held ultrasound scanner in routine patients referred for echocardiography. J Am Soc Echocardiogr 2011;24:111–6