Perioperative Use of Focused Transthoracic Cardiac Ultrasound: A Survey of Current Practice and Opinion.

BACKGROUND: The advent of portable ultrasound machines in recent years has led to greater availability of focused cardiac ultrasound (FoCUS) in the perioperative and critical care setting. To our knowledge, its use in the perioperative setting among anesthesiologists remains undefined. We sought to assess the use of FoCUS by members of the Society of Cardiovascular Anesthesiologists (SCA) in clinical practice, to identify variations in its application, to outline limits to its use, and to understand the level of training of physicians using this technology. METHODS: A 26-question anonymous and voluntary online survey assessing the participants' training level with FoCUS, frequency of use, and opinions regarding incorporating it into residency training and developing a pathway to basic certification. The survey was distributed to the members of the SCA via email. RESULTS: The survey was completed by 379 of 3660 members of the SCA (10%). Of the respondents, the majority (67%) had completed a cardiovascular anesthesiology fellowship with 58% identifying their practice as academic, while 37% stated they were in private practice, and 6% were military/Veterans Administration. Most (84%) of the respondents practiced in North America. Eighty-one percent reported familiarity with FoCUS, while 47% stated they use it in their clinical practice. Those practicing in North America were significantly less likely to utilize FoCUS in their practice as compared to other respondents. With regard to training and certification, 88% believe FoCUS education should be integrated into residency training programs and 74% believe there should be a pathway to basic certification for FoCUS. CONCLUSIONS: While most cardiovascular anesthesiologists are familiar with FoCUS, a minority have integrated it into their practice. Roadblocks such as lack of training, the fear of missing diagnoses, lack of resources, and the lack of a formal certification process must be addressed to allow for more widespread use of perioperative cardiac ultrasound.

Laryngeal mask airway placement in children prior to an intravenous line utilizing heart rate as an indicator of anesthetic depth.

INTRODUCTION: The usual practice in pediatric anesthesia cases requiring a laryngeal mask airway is to place an intravenous line (IV) prior to laryngeal mask airway placement. A different approach that has several clinical advantages is to place the laryngeal mask airway prior to the IV. We describe our experience with this technique, using heart rate as an indicator of adequate anesthetic depth. In addition, we analyzed heart rate data in children undergoing sevoflurane inductions, looking for age-related differences. METHODS: Following a sevoflurane induction, heart rates were recorded every 12 s for 3 min in 127 ASA I-II children under age 7. Laryngeal mask airway placement occurred when the heart rate dropped at least 10% from its maximum level or at 3 min. Ease of laryngeal mask airway placement was graded using a scale from 0 to 3. Endtidal sevoflurane concentration, occurrence of laryngospasm and blood pressure at laryngeal mask airway placement were also recorded. RESULTS: The laryngeal mask airway was successfully placed on the first attempt in all 127 children. Easy placement was noted in 98.4%. The youngest children's heart rates peaked earlier than the oldest (P < 0.001), while time to laryngeal mask airway placement increased with increasing age (P < 0.0001). CONCLUSIONS: Laryngeal mask airway placement before an IV is a safe alternative to the usual mask-IV-laryngeal mask airway sequence. Our data compare favorably to other studies where ease of laryngeal mask airway placement was reported. This technique has several advantages including securing the airway first for an anticipated difficult IV placement. Heart rate changes during a sevoflurane induction appear to be age-dependent.