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Be FoCUSed

The Time Is Now!

Skubas, Nikolaos J., MD, DSc, FACC, FASE*; Rehfeldt, Kent H., MD, FASE; Beattie, W. Scott, MD

doi: 10.1213/ANE.0000000000001800
Editorials: Editorial
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From the *Department of Anesthesiology, Weill Cornell Medicine, New York, New York; Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; and R. Fraser Elliot Chair in Cardiac Anesthesia, Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Canada.

Accepted for publication November 3, 2016.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Nikolaos J. Skubas, MD, DSc, FACC, FASE, Department of Anesthesiology, Weill Cornell Medicine, M-03-304C, 525 East 68th St, New York, NY 10065. Address e-mail to njs2002@med.cornell.edu.

Anesthesiologists adopt newer technologies and methods in the hope that these may improve perioperative care and outcomes. This adoption occurs even when the benefits of the technology have not been rigorously demonstrated (eg, pulse oximetry) or remain in question (eg, pulmonary artery catheter). Recently, anesthesiologists have adopted ultrasound as another technology ostensibly to improve patient care in a variety of clinical settings. In this issue of Anesthesia and Analgesia, Coker and Zimmerman present a narrative review1 and a simple, yet illustrative guide2 detailing the use of focused cardiovascular ultrasound (FoCUS) for perioperative hemodynamic assessment.

In very simple terms, FoCUS describes transthoracic, or surface, ultrasound imaging of the heart, inferior vena cava, and aorta to gain information about the status of the cardiovascular system at the point of care.3,4 Furthermore, FoCUS is an echocardiographic examination that can be employed as required by the clinical circumstance, from the preoperative setting to the postanesthesia care unit. One scenario where FoCUS may be of particular benefit is the expedient evaluation of the emergent surgery patient. It is important to emphasize that the scope of practice, and not the specific ultrasound machine used, defines FoCUS. Importantly, FoCUS does not replace a comprehensive echocardiographic examination that is typically performed by a licensed cardiac sonographer or physician.

FoCUS aims to qualitatively differentiate normal from pathologic findings, via the evaluation of size, anatomic appearance, and motion with two-dimensional echocardiography. Such evaluation is based on comparisons with the neighboring structures and recognition of motion patterns.5 For example, the physician performing FoCUS should be able to diagnose the presence of large pericardial or pleural fluid collections, marked enlargement of cardiac chambers, and may provide evidence of valvular heart disease. As the authors describe, such evaluation is relatively easy and fast, and provides important information. While the limited two-dimensional images generated during a FoCUS examination may provide clues to the presence of valvular heart disease, such as leaflet calcification or chamber enlargement, questions regarding severity of valve pathology cannot be definitively answered. Size determination is accomplished by visual estimation, based on comparison with neighboring structures. Attempts to measure exact dimensions are not only ill-advised, but also defeat the purpose of a FoCUS examination, which is, simply stated, “lean, mean, and quick.” Any information should be considered within the context of the overall clinical picture to be useful for the diagnosis or exclusion of a pathologic finding. When clinically indicated, the anesthesiologist should request further, more comprehensive imaging performed by an expert, if the FoCUS-derived information is limited.

The actual ultrasound machine may vary from expensive, stand-alone platforms, equipped with three-dimensional and strain rate packages, to pocket-sized devices capable only of two-dimensional imaging. It is precisely because of the limited imaging capabilities of some devices, and the abbreviated training of some interpreting physicians, that these tests aid clinical decision support, as opposed to diagnosis.

A timely question now is how to implement the use of FoCUS within our specialty. As described in practice guidelines documents3,4 and subjectively experienced by many transthoracic- or transesophageal-certified anesthesiologists, FoCUS is not bound by the practice and training rigors required for performing transthoracic or transesophageal echocardiography. As the technology advances and the size and cost of the FoCUS devices decrease, we anticipate that, as with the pulse oximeter, FoCUS will be ubiquitous in the very near future. The only remaining limitation to the widespread use of FoCUS will be our willingness to learn the technique and to adopt it. As an aside, current evidence suggests that FoCUS skills are quickly and easily acquired,6 although skills diminish if not practiced enough.7 Currently, critical care and emergency medicine,8,9 for example, have evaluated various scenarios that show adoption of FoCUS is an important triage or screening tool. In perioperative medicine, several small-scale or pilot studies10 suggest that the FoCUS examinations can change patient management. Similar types of studies need to be repeated on a larger, generalizable scale. It therefore follows that time has come for FoCUS to be critically evaluated to find its place in perioperative medicine.

As we add FoCUS to our perioperative diagnostic armamentarium, we should consider several key points. First, we need to remind ourselves that FoCUS is an abbreviated, focused ultrasound examination, aimed at answering simple questions in dichotomous fashion. Instead of trying to grade abnormalities as mild, moderate, or severe, we should instead look to answer clinical questions with responses of “yes or no,” and “present or absent.” As an example, the presence, or absence, of gross left ventricular functional abnormalities, the size of the ventricles, and the presence or absence of a pericardial effusion can be used to optimize the treatment of hypotension. Abundant, meaningful examination protocols using FoCUS already exist. It will be up to each individual to choose the FoCUS device/protocol that fits her or his type and style of practice.

Second, FoCUS should not be performed or interpreted in isolation. FoCUS should complement the physical examination and clinical judgment of the physician. For example, in the absence of related symptoms or an audible murmur, an abnormally appearing aortic valve detected during a FoCUS examination should not be the sole criterion for canceling an anesthetic and surgical procedure. Instead, it should be a reason to request additional imaging and an echocardiographic expert’s opinion, if the anticipated surgical risk is other than low.

Third, and more important, the implementation of FoCUS should be supported by experts in ultrasound imaging, such as trained anesthesiologists, intensivists,11 or, ideally, cardiologists. The adoption of transesophageal echocardiography into contemporary cardiovascular anesthesiology practice should serve as a model for in the incorporation of FoCUS into general anesthesia practice. The successful adoption of ultrasound imaging into the practice of cardiovascular anesthesiology occurred because the focus was on patient care, “not protecting practice silos and a source of income.” Although perioperative transesophageal echocardiography, when practiced by trained physicians, may be a billable service, the same cannot be said of FoCUS. FoCUS is not a billable procedure, and no such procedural code exists.

Finally, professionalism and introspection should guide the adoption of FoCUS. As important as it is for the “gurus” among us not to hinder the practice of FoCUS by noncardiovascular anesthesiologists, it is equally essential for the FoCUS zealots not to overestimate their diagnostic capabilities.

The clinical skill of FoCUS is now widely taught during the formative years of medical education, much the same as the use of a stethoscope.12 Indeed, we should make ultrasound imaging, in general, and cardiovascular ultrasound imaging, in particular, a required clinical skill during anesthesiology training. Anesthesiologists currently are using ultrasound to perform nerve blocks, estimate intracranial pressure, diagnose pneumothorax or pleural fluid, or even detect endotracheal intubation.13 It is time to explore and hopefully realize the full clinical potential of perioperative FoCUS for the optimal care and outcomes of our patients.

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DISCLOSURES

Name: Nikolaos J. Skubas, MD, DSc, FACC, FASE.

Contribution: This author helped analyze the data and write the manuscript.

Name: Kent H. Rehfeldt, MD, FASE.

Contribution: This author helped analyze the data and write the manuscript.

Name: W. Scott Beattie, MD.

Contribution: This author helped analyze the data and write the manuscript.

This manuscript was handled by: Thomas R. Vetter, MD, MPH.

Acting EIC on final acceptance: Thomas R. Vetter, MD, MPH.

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REFERENCES

1. Coker BJ, Zimmerman JM. Why anesthesiologists must incorporate focused cardiac ultrasound into daily practice. Anesth Analg. 2017;124:761–765.
2. Zimmerman JM, Coker BJ. The nuts and bolts of performing focused cardiovascular ultrasound (FoCUS). Anesth Analg.2017;124:753–760.
3. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26:567–581.
4. Via G, Hussain A, Wells M, et al; International Liaison Committee on Focused Cardiac UltraSound (ILC-FoCUS); International Conference on Focused Cardiac UltraSound (IC-FoCUS). International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014;27:683.e1–683.e3.
5. Holm JH, Frederiksen CA, Juhl-Olsen P, Sloth E. Perioperative use of focus assessed transthoracic echocardiography (FATE). Anesth Analg. 2012;115:1029–1032.
6. Schnobrich DJ, Olson AP, Broccard A, Duran-Nelson A. Feasibility and acceptability of a structured curriculum in teaching procedural and basic diagnostic ultrasound skills to internal medicine residents. J Grad Med Educ. 2013;5:493–497.
7. Kimura BJ, Sliman SM, Waalen J, Amundson SA, Shaw DJ. Retention of ultrasound skills and training in “point-of-care” cardiac ultrasound. J Am Soc Echocardiogr. 2016;29:992–997.
8. Kameda T, Taniguchi N. Overview of point-of-care abdominal ultrasound in emergency and critical care. J Intensive Care. 2016;4:53
9. Whitson MR, Mayo PH. Ultrasonography in the emergency department. Crit Care. 2016;20:227
10. Kent A, Bahner DP, Boulger CT, et al. Sonographic evaluation of intravascular volume status in the surgical intensive care unit: a prospective comparison of subclavian vein and inferior vena cava collapsibility index. J Surg Res. 2013;184:561–566.
11. Fagley RE, Haney MF, Beraud AS, et al; Society of Critical Care Anesthesiologists. Critical care basic ultrasound learning goals for American anesthesiology critical care trainees: recommendations from an expert group. Anesth Analg. 2015;120:1041–1053.
12. Nelson BP, Hojsak J, Dei, Rossi E, Karani R, Narula J. Seeing is believing: evaluating a point-of-care ultrasound curriculum for 1st-year medical students. Teach Learn Med. 20161–8.
13. Ramsingh D, Rinehart J, Kain Z, et al. Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents. Anesthesiology. 2015;123:670–682.
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