Episode 337: TEE for the non-cardiac Anesthesiologist with Andreas Plackis

[SPEAKER_01]: Hello and welcome back to Accrax. [SPEAKER_01]: I'm Jed Wolpa and I am thrilled to have a fabulous show today on something really really important and in the cutting edge of what we want to be thinking about and that is thinking about TEE for the non cardiac anesthesiologist and I have a perfect guest to talk about this today.

[SPEAKER_01]: Dr. Andreas Placcus is a Vanderbilt train cardiac anesthesiologist. [SPEAKER_01]: and the creator and host of the first of its kind, Perry operative transosophageal echo podcast called TEE Time, which I highly recommend you check out. [SPEAKER_01]: Of course, we'll have links in the show notes.

[SPEAKER_01]: He's a board certified anesthesiologist, also cardiac anesthesiologist, and he's board certified in advanced Perry operative transosophageal echo and critical care echo, and in full time clinical practice in Arkansas. [SPEAKER_01]: He trained at Vanderbilt, as I said, and now practices near his family in Arkansas.

[SPEAKER_01]: I'm thrilled to have him on the show, Andreas, welcome to Akraq. [SPEAKER_02]: Well, thanks so much for having me. [SPEAKER_02]: It's great to be here. [SPEAKER_01]: So tell me a little bit about you. [SPEAKER_01]: How you got interested in TE, not just as any old cardiac anesthesiologist who, you know, of course is going to use it, but how did you develop an interest to took you all the way to starting a podcast about it?

[SPEAKER_01]: Tell me a little bit about that. [SPEAKER_02]: Yeah, so TE has been a passion of mine for a number of years. [SPEAKER_02]: I think specifically as it relates to the podcast, it dates back to the start of my cardiac anesthesia fellowship at Vanderbilt. [SPEAKER_02]: At that time, what's unique about cardiac surgical cases is in addition to prepping for all the other things, like anesthesia considerations or surgical considerations, [SPEAKER_02]: You need to learn how to use TEE to help in those cases, such as what to do in the pre-bi-pass period when you're on cardiovascular pulmonary bypass or in the post-bi-pass period.

[SPEAKER_02]: During fellowship, one thing I had difficulty with was finding concise, high yield resources to help me prepare for TEE during those cases. [SPEAKER_02]: Essentially, find a resources that say, here's what you need to know if you're performing a mitral valve replacement. [SPEAKER_02]: or you know, if that's being performed by the surgeon and Eric Fauver placement, heart transplant, lung transplant, here's what you need to know.

[SPEAKER_02]: So because of some of that difficulty, I took on this big educational project during my fellowship where I made this big written manual that was summarizing perioperative TE considerations for [SPEAKER_02]: really all kinds of different cardiac surgery cases. [SPEAKER_02]: And by the end of the year, I want to say it was over 60 pages long, you know, one page for each type of surgery.

[SPEAKER_02]: And that document is still used by trainees at that institution today. [SPEAKER_02]: But over the years, being out in practice, I've added to it. [SPEAKER_02]: And I've always had this itch. [SPEAKER_02]: wondering what it would be like if I added video and commentary to this written content to essentially bring it to life.

[SPEAKER_02]: And so that's how the idea for the T-time podcast was born from there. [SPEAKER_02]: That's awesome. [SPEAKER_01]: Yeah and I love that especially just as an example of when you have that [SPEAKER_01]: interest, you know, and you kind of think, oh, you know, I would love to be able to disseminate this or help people with this or I just really passionate about this, you know, find a way to to capitalize on that, you know, a lot of people, I have a lot of residents who kind of think, well, I don't, I don't love traditional research.

[SPEAKER_01]: So I guess academics is not for me and I'll tell them, you know, first of all, academics, no academics. [SPEAKER_01]: finding an area of interest is going to make your career more rewarding and if you are interested in academics it doesn't have to be traditional research you know do a podcast do a you know make some modules make a manual right i mean there's lots of ways you can do teaching and make curriculum that isn't [SPEAKER_01]: traditional research.

[SPEAKER_01]: And so you have found a way to take that interest in TE that's not just in using it clinically, but in kind of teaching it and disseminating knowledge about it. [SPEAKER_01]: And you made this podcast, which is fabulous. [SPEAKER_01]: And as I said, I really recommend people checking out.

[SPEAKER_01]: Yeah, well, thank you. [SPEAKER_01]: Yeah. [SPEAKER_01]: So let's talk about, obviously, the cardiac anesthesiologist is going to use TE all the time. [SPEAKER_01]: But what about the noncardiac anesthesiologist? [SPEAKER_01]: Tell us a little bit about where you see TE [SPEAKER_02]: Yeah, so there's a few specific areas that I can think of specifically in high-risk non-cardiac surgeries.

[SPEAKER_02]: I think of any time there's a risk of significant hemodynamic compromise during a surgery. [SPEAKER_02]: There's select types of trauma surgery, high-risk vascular surgeries. [SPEAKER_02]: certain transplant surgeries, but any time you can think, would my patient potentially be at high risk of human dynamic compromise?

[SPEAKER_02]: And I know we'll talk about the next one later, but the next one is emergent cases or emergent situations where it can be used as a rescue tool for managing patients with severe hypotension and cardiac arrest. [SPEAKER_02]: I will say, as well, it's worth mentioning that for trainees, specifically anesthesia residents, TE is on the content outline for the ASCII portion of the ABA applied exam.

[SPEAKER_02]: So if for no other reason, this is something that could be showing up on future tests for that group of people. [SPEAKER_01]: Yeah, absolutely. [SPEAKER_01]: Is there a role for none, anesthesiologist, to be using TE do you think? [SPEAKER_02]: Yeah, you know, I think the scope of practice is always changing and evolving.

[SPEAKER_02]: Two groups that I would mention would be the emergency department physicians. [SPEAKER_02]: I frequently see it used and taught more in those settings. [SPEAKER_02]: In the operating settings, we call it rescue TE when we use it emergencies, but in emergency departments, it's known as recessive-tative-recessive-tative TE, so that's one area where it's growing.

[SPEAKER_02]: And then the other area is with intensivists and clinical practice that are seeking more and more formal training. [SPEAKER_02]: For example, I know a few pulmonology intensivists that came out of training with no familiarity with TE that have gone and sought their own formal training. [SPEAKER_02]: And now they use it in the care of critically ill patients as well.

[SPEAKER_01]: Yeah. [SPEAKER_01]: That's fascinating. [SPEAKER_01]: I was not aware that it's being used in the emergency department. [SPEAKER_01]: I don't think it's yet made an appearance on the pit, but I'm sure it's only a matter of time. [SPEAKER_02]: Well, and because it's so useful, I can imagine that as the scope changes, it's one of those things that we'll see more and more.

[SPEAKER_01]: Yeah, I'm sure you're right. [SPEAKER_01]: And it makes a lot of sense for ED docs, at least in, you know, [SPEAKER_01]: busy trauma centers in the ICU, even for nine anesthesiologists, so I mean it all makes sense that this should be done. [SPEAKER_01]: Now the question that of course is going to be on a lot of anesthesiologists and trainees minds is, you know, why do I need TE if I have TE, right?

[SPEAKER_01]: We kind of think of and I think a lot of people talk about trans thoracic echo as the real tool of the non-cardiac anesthesiologists being able to use this in the ICU, we do it all the time of course. [SPEAKER_01]: So, what's your answer to that? [SPEAKER_01]: Why would someone need TE if they have TE?

[SPEAKER_02]: Yeah, well, I'll speak specifically to the perioperative setting because there's a lot of indications, you know, outpatient indications, all that, but I'll speak specifically to perioperative settings, comparing the two, some of the advantages of TE would be thinking of your views, frequently you're able to obtain views faster, and in most settings obtain superior quality views, especially in patient populations such as patients with high BMI, open chest or chest wall [SPEAKER_02]: putting a TTE probe might not be feasible to obtain views and then I mentioned in emergency settings some of the advantages in those settings would be the ability to monitor a patient hands-free.

[SPEAKER_02]: So what you can do is place a TE probe, get your view on the screen and then continue to do other things to help care for a patient in an emergency. [SPEAKER_02]: Whereas with a TTE probe, [SPEAKER_02]: or dedicate a hand to holding that TTE probe on the chess wall and you're unable to do other things while you're doing that specifically.

[SPEAKER_02]: Another part worth mentioning in emergencies is that TE does not interrupt CPR, which is an important quality of high quality chess compressions as minimal interruptions if possible. [SPEAKER_02]: I think the last thing that I can think of is for procedural guidance, especially keeping in mind mechanical circulatory support.

[SPEAKER_02]: T.E. [SPEAKER_02]: is very helpful for locating wires, position and canyons, or other types of devices as well. [SPEAKER_01]: Yeah, and I can't tell you how many times in certainly the OR, we think wouldn't it be great to be able to put a trans thoracic pro bond, but it's under the drapes, they're prone, you know, whatever maybe.

[SPEAKER_01]: And then, [SPEAKER_01]: in the ICU also there's a lot of times where you have a patient who have they have dressings on their chest you just can't get good windows through the chest they've got a big abdominal incision that's high enough that you can't do a subcastle you know there's a lot of times in both the over and the ICU where you can't use a TTE but presumably many of those you could use a T.E now let me ask you I remember years ago [SPEAKER_01]: there was this idea that we would at some point have sort of lower profile TE probes you know that weren't as big that you could maybe leave in for more extended period of time like in the ICU are those do you know are those in use or we really just still dealing with what I used as a resident on cardiac the kind of standard big TE probe.

[SPEAKER_02]: Yeah, I can't speak specifically to those because I've never personally used them, but I'm aware of devices that are made one with smaller profile, especially for patients that have things like a soft needle strictures. [SPEAKER_02]: Some people call them pediatric TE probes. [SPEAKER_02]: And then there's some, you see some studies out there where they talk about leaving a probe in for up to 72 hours and certain disposable TE probes are made for that purpose as well.

[SPEAKER_02]: I haven't seen those implemented in clinical practice, but they're definitely out there. [SPEAKER_01]: Okay, yeah, I think we would, I imagine we might see more of that over time. [SPEAKER_01]: Let's talk about rescue TE. [SPEAKER_01]: What does that mean and what are the goals of rescue TE?

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[SPEAKER_01]: We rely on true learn for our test prep, and I recommend you do the same, www.truelearn.com and use code ACRAC. [SPEAKER_01]: All right, and now we're back talking about rescue TEE. [SPEAKER_02]: Um, rescue TEE is something that I'm passionate about. [SPEAKER_02]: I even dedicated a three-part series in my podcast to it episodes 15, 16, and 17.

[SPEAKER_02]: But think about rescue TEE as a problem-focused TEE exam, where you can... [SPEAKER_02]: In emergencies, you can diagnose pathology, guide interventions, and even monitor therapeutic response, and specifically for patients with unexplained persistent hypotension, hypoxemia, or cardiac arrest.

[SPEAKER_02]: And the major goals of performing the exam are to help differentiate the type of shock and possible causes for that shock. [SPEAKER_02]: So that's the goal when we're thinking about using [SPEAKER_02]: And I'll reiterate that it is not a comprehensive exam. [SPEAKER_02]: It's a problem-focused exam, because the goal here is to make a diagnosis and accurate diagnosis as quickly as possible, so speed matters in these exams.

[SPEAKER_01]: Yeah, and that, you know, I think most trainees these days are gonna be familiar with that because really in the ICU's, that's what we do with the TTE, right? [SPEAKER_01]: We rarely are doing a complete exam. [SPEAKER_01]: We are saying, okay, you know, I need to know about volume status.

[SPEAKER_01]: So I'm gonna look at a couple quick things, or I'm worried there could be tamponaut, I'm gonna just look for a paracardial effusion really quick, right? [SPEAKER_01]: Or I'm worried about right-hard failure, I'm gonna quickly see what the right-hard looks like, [SPEAKER_01]: the entire echo, um, uh, cardiac echo.

[SPEAKER_01]: So that not that no one could do that. [SPEAKER_01]: And certainly people are trained to do that as you are and can, but often we're using a very targeted approach. [SPEAKER_01]: And so that's what it sounds like you're talking about, too. [SPEAKER_01]: Yep, exactly. [SPEAKER_01]: How about perioperatively, uh, how are we thinking about using this perioperably versus, let's say, like an out of hospital arrest?

[SPEAKER_02]: Yeah, so there's a few unique considerations specific to the parioperative period. [SPEAKER_02]: The first one I think of is imagine someone laying down in a field, this is out of hospital arrest compared to in the OR setting. [SPEAKER_02]: Patients have witnessed arrests. [SPEAKER_02]: They're on monitors and there's abundant resources all around.

[SPEAKER_02]: So this often will lead to more timely diagnoses and treatment. [SPEAKER_02]: They're oftentimes in an ideal state already, which is intubated, sedated, and paralyzed, so they're ready for TE placement. [SPEAKER_02]: It is worth mentioning that if a patient is, if it's a sedation type case, mac case, or if there's an LMA in place, it is safer to exchange that for an endotracheal tube, prior to using TE, so you have a definitive airway.

[SPEAKER_02]: You can use it safely. [SPEAKER_02]: The other things would be positioning in the OR setting, compared to [SPEAKER_02]: an out of hospital setting, patients could be prone, they could be lateral, there could be difficult access to them if a bed is spun 180 degrees or even thinking about surgical drapes or equipment that may affect access to the patient.

[SPEAKER_02]: And I'd say the last thing that is a major difference is thinking through the differential diagnosis. [SPEAKER_02]: We're in [SPEAKER_02]: The pair-up of setting, you oftentimes will have anesthesia or surgery-related adverse events causing a cardiac arrest compared to something like eschemic heart disease, which would be much higher on the differential for an out-of-hospital arrest.

[SPEAKER_01]: Right. [SPEAKER_01]: Yeah, that makes a lot of sense. [SPEAKER_01]: Okay. [SPEAKER_01]: And then, where are you thinking, yeah, this is like a really good candidate for it and who are candidates that you would say, just that's contrainicated, we can't do it. [SPEAKER_01]: I mean, I guess one obvious one is a soft geostructure, that kind of thing, but, you know, what else do you think about?

[SPEAKER_02]: Yeah, so we're thinking about indications, contraindications, the indications which touched on briefly would be any unexplained persistent hypotension, hypoxemia, or cardiac arrest, and then also things like new aridmias or eschemic EKG changes. [SPEAKER_02]: As far as when a TE approach should not be placed, overall it's worth mentioning that this is a generally a very safe procedure.

[SPEAKER_02]: rate of complications and and a less than 0.1% chance of any major complications such as in a soft deal perforation or major bleeding. [SPEAKER_02]: Some of the absolute contraindications worth mentoring mentioning would be major esophageal or gastric injuries or obstructions or acute bleeding in those sites.

[SPEAKER_02]: It [SPEAKER_02]: There is a number of relative, or there are a number of relative contraindications as well, and these, especially in a rescue setting, these deserve a thorough risk versus benefit evaluation, because especially if a patient's coding, there may be a whole lot of benefit you can offer, and that risk versus benefit analysis may look different compared to, you know, just in a plan surgery.

[SPEAKER_01]: Yeah. [SPEAKER_01]: And it seems to me like one of the classic times we think about wanting to place a swan in the ICU is that undifferentiated shock. [SPEAKER_01]: We're trying to figure out, is this cardio genica is the septic or is it both? [SPEAKER_01]: And this seems like a great substitute for swan.

[SPEAKER_01]: If you can get that idea, you should be able to tell if there's a cardio genica component or if it isn't, right? [SPEAKER_01]: If the heart is hyper dynamic, it looks great, but there, you know, [SPEAKER_01]: So that seems like a great use. [SPEAKER_01]: I'm talking about the rescue exam itself.

[SPEAKER_01]: So what are you looking at? [SPEAKER_01]: How are you doing it? [SPEAKER_02]: Yeah, and maybe I can even touch on what you just mentioned, the types of shock and all that, even because I think it sets up well of framework for how to think about the TE imaging protocols. [SPEAKER_02]: If that's all right with you.

[SPEAKER_02]: Of course. [SPEAKER_02]: Yeah, let me, so as far as thinking through the different types of shock and causes of cardiac arrest, like some of what you mentioned, there's another different ways that are taught. [SPEAKER_02]: Some, you think, back even to med school, thinking through the H's and T's of cardiac arrest and memorizing that list that was 10 and now it's 12 and going through all of those, you mentioned those types of shock, the four types, like hypovalemic, distributive, [SPEAKER_02]: One thing that helps me in a rescue TE setting is trying to think as anatomically as possible.

[SPEAKER_02]: So, understanding cardiac anatomy and thinking through, essentially with my rescue exam, I'm looking anatomically at the heart to try to understand what's going on. [SPEAKER_02]: So, I use the acronym P-Car and you may have heard this, but it stands for preload, [SPEAKER_02]: Now, these are all factors that influence cardiac output.

[SPEAKER_02]: So if one of them is very abnormal, it can lower cardiac output or blood pressure. [SPEAKER_02]: And the only thing, instead of memorizing a big list, all I have to think about and know is, I ask the question, how does blood flow through the heart and the body and where can things go wrong in that pathway?

[SPEAKER_02]: So how does blood flow through the heart and the body and where can things go wrong in that pathway? [SPEAKER_02]: And for each of these terms, the left ventricle is the reference point for the entire evaluation. [SPEAKER_02]: So thinking anatomically pre-load, here would be considered factors preventing blood from reaching the left ventricle.

[SPEAKER_02]: And a distinction to be made to make with most people when they think of pre-load, they think of only hypovolemia. [SPEAKER_02]: But RV failure as well would cause low pre-load to the left ventricle. [SPEAKER_02]: Contractility is contractility would be defined as LV factors like global or regional LV dysfunction.

[SPEAKER_02]: After low would be factors downstream of the left ventricle, and these could be high or low after low, or it can also be broken into intra cardiac or extra cardiac causes. [SPEAKER_02]: And then just around it out, rate and rhythm would be a reduced number of adequate stroke volumes per minute.

[SPEAKER_02]: think with me in your head about the way blood flow through the body and how it can be categorized in each one of these terms starting in the peripheral circulation where there could be bleeding or hypovolemia and then blood travels back to the heart through the IVC or SVC where there could be compression of those vessels then into the right atrium where something like cardiac tamponaut could cause chamber compression blood flow through the tricuspid valve and then into the [SPEAKER_02]: the right ventricle where RV failure could be present through the pulmonic valve into the pulmonary arteries where pulmonary hypertension or a PE could be obstructing blood flow.

[SPEAKER_02]: Then from the pulmonary arteries to the lungs where something like length pathology, attention to mothorax or auto-peat for example, would cause problems before blood finally heads to the left side of the heart where mitral valve pathology would be. [SPEAKER_02]: So that is the framework I have [SPEAKER_02]: And then after load, I basically just start with the left ventricle and keep the path of blood flow through the LVOT, where LVOT obstruction could be present, then there's aortic valve pathology or extenosis or degree of irritation, then in that proximal ascending order and aortic dissection could be present.

[SPEAKER_01]: Stay with us, we'll be right back. [SPEAKER_02]: All right, and we're back. [SPEAKER_02]: And then you keep traveling the path of blood out to the periphery again and think about causes of low after low, the distributive shock, anoflaxis, neurogenic shock, anesthesia related base of dilation or sepsis.

[SPEAKER_02]: So I know that's a worthy way of explaining it. [SPEAKER_02]: The path of blood flow, but if you can imagine it in your head, [SPEAKER_02]: you have a framework that's very anatomic and echo is looking at it anatomically. [SPEAKER_02]: So I think these ways are really helpful ways to integrate both an exam and a mental framework.

[SPEAKER_02]: So you're not thinking in one train of thought and looking with another when you're using echo. [SPEAKER_02]: So [SPEAKER_02]: Getting to your question about imaging protocols. [SPEAKER_02]: What do I actually do when I'm doing a rescue TE? [SPEAKER_02]: Well, you'll find a number of different rescue TE protocols.

[SPEAKER_02]: There's not one true absolute way to do it. [SPEAKER_02]: I'll share the way that I teach in my podcast, which is a combination of two different published exams. [SPEAKER_02]: And because I go into so much detail in my podcast, I separate these in a three steps, but I'm going to simplify it here into two parts.

[SPEAKER_02]: the first is the initial evaluation. [SPEAKER_02]: So this is getting three different TE views and trying to answer the question, is there a problem with preload, contractility, or afterload? [SPEAKER_02]: And then part two is performing the rest of the complete basic period of TE exam and then other advanced views or maneuvers from here to solidify diagnosis and ensure that there's no finding that's missed.

[SPEAKER_02]: And when you look at [SPEAKER_02]: In emergencies, when they're high stress and you can lose some of your footing a little bit, I think systematically evaluating the heart can be a strength. [SPEAKER_02]: And so when I look at any echo clip in this framework, I think of the words in at and around.

[SPEAKER_02]: I want to look in the heart, look at the heart and look around the heart. [SPEAKER_02]: So I'm looking in the heart for that volume status and for [SPEAKER_02]: I'm looking at the heart for LV RV dysfunction and looking at the valves. [SPEAKER_02]: And when I evaluate valves, it's both with and without color flow Doppler.

[SPEAKER_02]: And the valve evaluation here is not a, I'm trying to discern between mild and moderate. [SPEAKER_02]: It's trying to make it as black and white as possible. [SPEAKER_02]: Does the valve open and does it close? [SPEAKER_02]: Is there good leaflet excursion? [SPEAKER_02]: Where there is unlike to be significant stenosis?

[SPEAKER_02]: And does it close properly? [SPEAKER_02]: Does it co-app to well? [SPEAKER_02]: And there's no major, regurgitant jet. [SPEAKER_02]: And then I mentioned around, I look around the heart for fluid collections, compression of heart chambers. [SPEAKER_02]: So looking in and around the heart can be helpful when you look at images.

[SPEAKER_01]: Yeah, that's great. [SPEAKER_01]: That's a great way to think about it. [SPEAKER_01]: And my right that, like when you're looking at the valves, you don't need to, not that it wouldn't be fine to do. [SPEAKER_01]: But you don't need to be kind of calculating an exact cardiac output or measuring the exactly the VTI.

[SPEAKER_01]: I mean, you're really trying to get [SPEAKER_01]: correct me if I'm wrong but you're trying to get an idea of like is there is the problem right because that you don't know not doing rescue t unless there's a problem so you have a very high potential patient let's say or even a resting patient and you're trying to figure out is the problem that they have you know critically or still says or wide open MR right like you're just trying to get like yes or no is this the cause of my problem [SPEAKER_02]: Yeah, I think that's a great point that most times in a rescue setting, especially with severe severe high-potention or even cardiac arrest, your findings in TE are usually not subtle.

[SPEAKER_02]: You're not teasing out something. [SPEAKER_02]: It's usually more obvious and you just need to make the diagnosis quickly and accurately. [SPEAKER_02]: I will say depending on how deep and how advanced you want to get into TE, things like cardiac output and even LVOTVTI can serve a purpose.

[SPEAKER_02]: And I mentioned, I'll even take it through exactly some of the details of how I do the evaluation because I think it's up to the provider as far as how many tools do they want in their tool belt when they're performing rescue TE. [SPEAKER_02]: But I mentioned in part one of, in evaluation, your trying to assess is the, their problem with preload, contractility, or afterload.

[SPEAKER_02]: And the views that I use are three-folder. [SPEAKER_02]: The three highest yield views in a rescue exam. [SPEAKER_02]: It's a midsoft yield four-chamber view, a midsoft yield long access view, and a transgastric mid-pablo short access view. [SPEAKER_02]: And if you have a background in TTE, you'll realize that these views are analogous to the apical four-chamber view, the peristinal long access view, and the peristinal short access view.

[SPEAKER_02]: It's the same structures just different orientations. [SPEAKER_02]: So, again, trying to keep it simple up front and work through some of these anatomic frameworks quickly, there's a decision tree that I follow. [SPEAKER_02]: And the first question I asked myself, is the LD systolic function depressed?

[SPEAKER_02]: Because that would make me think there could be a problem with contractility. [SPEAKER_02]: If there's normal LV systolic function and the LV size is normal in diastly, then I start thinking if there could be a problem in the afterload category. [SPEAKER_02]: And then the third one is if there's normal LV systolic function and there's an underfilled LV in diastly, something is preventing blood from reaching the left heart.

[SPEAKER_02]: So that would be a problem with preload. [SPEAKER_02]: And I'll give the caveat here that there are exceptions to a number of these rules. [SPEAKER_02]: There can be multiple problems in the same patient. [SPEAKER_02]: Think about anoflaxis that could cause a relative hypopholemia and a problem with preload in addition to low afterload.

[SPEAKER_02]: So there can be multiple of these things that co-exist. [SPEAKER_02]: But with that caveat, there's one more question that I ask about preload to further differentiate in that anatomic pathway. [SPEAKER_02]: or I look at the right ventricle next. [SPEAKER_02]: If the right ventricle is dilated and hypokinetic, then I start thinking that pathology may be at the right ventricle or downstream towards the left side of the heart.

[SPEAKER_02]: Where you think there could be pressure overload from a PE, pulmonary hypertension, volume overload from tracuspid or pulmonic regurgitation or from volume overload in general. [SPEAKER_02]: The other side of that coin is if the LV is small and the RV is small with preserve function, then I think pathology very likely could be prior to the right ventricle.

[SPEAKER_02]: Hypovalemia, IVC compression, or abdominal compartments syndrome, even tamponaut compressing the right atrium. [SPEAKER_02]: I will say the exception to this is lung pathology. [SPEAKER_02]: So attention pneumothorics cannot be definitively diagnosed with TE and it can make a heart look hypovalemic during a TE exam.

[SPEAKER_02]: For this reason, I advocate that any machine that you're performing a rescue TEE with also have a linear probe to be performing lung ultrasound. [SPEAKER_02]: If you can quickly look for lung sliding, lung point, and other findings of attention to methorax, that's just one more tool you have in these rescue settings.

[SPEAKER_02]: So that's, that's, [SPEAKER_02]: Part one, this is the three views. [SPEAKER_02]: I'm trying to discern these things from the three views before I go into part two, which is trying to be more thorough, performing more advanced views, to solidify my diagnosis and sure no findings are missed.

[SPEAKER_02]: And the standard basic, perioperative TE exam that's, [SPEAKER_02]: that's offered by the American Society of Eccocardiography, I think the articles from 2013 or the guideline was from 2013, is a standard 11-view exam, so you've already performed three views so far, but the reason these other views matter is because there's other things that you might not be able to catch with just those three views that are important in a rescue setting and other advanced maneuvers you can do.

[SPEAKER_02]: Some of those things would be like diagnosing an aortic dissection, which you need other views of the Aorta to see. [SPEAKER_02]: Looking for a pulmonary embolism and getting better views of the main and right pulmonary artery. [SPEAKER_02]: Being able to rule out concert indications to mechanical circulatory support is another step here because sometimes the end pathway of care of some of these patients is on VA ECMO or with an impella.

[SPEAKER_02]: So ruling out some of those concert occasions is important. [SPEAKER_02]: I mentioned linear probes and evaluating hypoxemia, but there's things you can do with TE as well. [SPEAKER_02]: And then the last, which you already mentioned, is further evaluating patients with hypovalemia or for fluid responsiveness.

[SPEAKER_02]: So that's where some of those things like LVOTVTI variability or even measuring cardiac output. [SPEAKER_02]: If you want to get more advanced in rescue TE, having some of those tools can help. [SPEAKER_02]: They're not mandatory, but I say, [SPEAKER_02]: the more trained you are and the more tools you have, the more it can potentially aid you in a rescue setting.

[SPEAKER_01]: And Andreas, what would be something you'd find on TEE that would be a make-up patient a contra indication for our ECMO? [SPEAKER_02]: Yeah, so things that I would consider, I'd want to evaluate the venocide and the overexide. [SPEAKER_02]: The venocide, I think, about significant right-eat-fill masses or thrombus, or even identifying QR networks that might make placing a wires difficult, sometimes wires can get caught in that and make locating or placing the cannula is difficult.

[SPEAKER_02]: Then from the aeroxide, things like severe aortic insufficiency and acute aortic dissection, mobile plaques in the aeroida, have seen surgeons place them in a number of these situations, because sometimes it's all you can do, but these are some of the contraindications that at least be looking for to try and alert whoever's accumulating the patient for VA ECMO.

[SPEAKER_01]: Great. [SPEAKER_01]: So what are some pro tips that you would give people who are going to try this out tomorrow? [SPEAKER_01]: What should they keep in mind? [SPEAKER_02]: Yeah. [SPEAKER_02]: One warning I would give is make sure no matter what you're completing a full exam each time. [SPEAKER_02]: I think it's really easy and emergency settings to find a diagnosis and then stop looking at that point.

[SPEAKER_02]: But as we mentioned already multiple [SPEAKER_02]: complete the full exam each time and then if the clinical status changes start over and do your exam from the beginning and do the full exam again because there can be new findings, patients are critically ill and new things can be unveiled with time.

[SPEAKER_02]: Another tip I give is for you individually and even for a hospital setting, thinking through the rate limiting steps [SPEAKER_02]: to the time of diagnosis and treatment to make that time as short as possible. [SPEAKER_02]: And one tip I was given a number of years ago that I just find so simple, but so useful is a rate limiting step here can be turning on the TE machine.

[SPEAKER_02]: So some TE machines take two or three minutes to start. [SPEAKER_02]: So if I'm called to a room, I try one thing I tell them before I hang up the phone is plug in the machine and turn it on please because I'm on my way. [SPEAKER_02]: Or if it's me in the room, [SPEAKER_02]: I want to plug the machine in and turn it on before I've even placed the probe.

[SPEAKER_02]: It's the first thing I do, not the last thing I do, because there's nothing more frustrating than trying to help a patient emergency and your equipment's not working yet. [SPEAKER_02]: And then I think the final tip I'd give is thinking about the rescue TE machine setup. [SPEAKER_02]: I mentioned already having a linear probe available, and then even having a phase to ray probe as well.

[SPEAKER_02]: That way, your rescue team, I think it's a more complete rescue setup when you can perform lung ultrasound, perform lines with it, central lines, arterial lines, using a phase array probe if you're deciding between TTE or TE. [SPEAKER_02]: You can call for one machine that can accomplish all of these tasks.

[SPEAKER_01]: Yeah, that makes a lot of sense. [SPEAKER_01]: All right, let's say that someone is low loving this. [SPEAKER_01]: They say, I want to be able to do this, but man, I don't know how to do T. So what's the little? [SPEAKER_01]: Give a little bit of an overview of like a beginner's guide to T. E. Where should people start?

[SPEAKER_01]: What should they keep in mind? [SPEAKER_01]: What are some resources they can out them out? [SPEAKER_02]: Yeah, and I've been asked this question a bunch of times. [SPEAKER_02]: I actually decided to make a podcast episode about it. [SPEAKER_02]: It's episode 14, the best way to learn TE and pass the basic or advanced PTE exam, and I go into a lot of detail, but I'll summarize some of the high points for you here.

[SPEAKER_02]: I think there's three main components to learning TE that I can think of. [SPEAKER_02]: It's learning what to do with your hands, learning what to do with the machine, and then interpreting images. [SPEAKER_02]: So as far as learning what to do with your hands, [SPEAKER_02]: describe how to place a TE probe or even probably more significantly how to manipulate the probe to successfully obtain views.

[SPEAKER_02]: The resource that I would recommend if your hospital has access to this is a simulator, a TE simulator, and because that's a good way in a low pressure environment where there's no time pressure related to a case moving forward, like can occur in a cardiac surgery operating room. [SPEAKER_02]: to learn how to use your hands, manipulate the probe, how to get 2D views of three dimensional structures, and then using this in conjunction with the, this is one of my favorite resources, but the Toronto General Hospital Virtual TE website.

[SPEAKER_02]: This is one of the best websites I found at [SPEAKER_02]: at being able to show you all the TEVs and all the relevant anatomy you can spin images. [SPEAKER_02]: It just gives you a great understanding of a three-dimensional space. [SPEAKER_02]: So with those two views, I'd recommend it.

[SPEAKER_02]: If you're very new to TEV, you can set up that website on an iPad or a tablet or even a computer. [SPEAKER_02]: and use a simulator to help practice until you can obtain all those views yourself with your hands. [SPEAKER_02]: It's not required to have a simulator you can do this with cases.

[SPEAKER_02]: I just find it's a little bit lower pressure, lower pace environment. [SPEAKER_02]: You can take as much time as you want. [SPEAKER_02]: So that's what to do with your hands. [SPEAKER_02]: Thinking about what to do with a machine. [SPEAKER_02]: This is, you use the word no biology to describe this.

[SPEAKER_02]: And the first time you look at a TE machine, it can kind of be like walking into an airport. [SPEAKER_02]: or, excuse me, in a paper plane, copped out where there's a million knobs and you're not sure what they do, but you gotta know how to use them. [SPEAKER_02]: But what you'll find is as you learn more and more about echocardiography, some of these things will start making sense, what color Doppler is, pulsewave Doppler, you know, all those different buttons and what they do.

[SPEAKER_02]: One suggestion I would give to help, [SPEAKER_02]: take a jump in your learning for the machine is ask your mentor or in attending your working with if they wouldn't mind if if the if the clinical situation allows to not touch the machine so your hands can do everything have them talk you through it because there's a big advantage to building that muscle memory and seeing exactly how when your hand touches this knob here's how it changes my my exam and my images and and and just being able to relay that so you can do it more on your own next time.

[SPEAKER_02]: I mentioned the third one is interpreting images. [SPEAKER_02]: This is the one I think that takes the longest time to learn. [SPEAKER_02]: You're learning what normal cardiac anatomy looks like. [SPEAKER_02]: But more importantly, the challenging one is making diagnoses learning what abnormal cardiac anatomy looks like.

[SPEAKER_02]: And there's just no substitute for repetition and cases. [SPEAKER_02]: So getting your [SPEAKER_02]: hands-on as many cases as you can perform with strong mentors and attendings that can help teach you. [SPEAKER_02]: Even if it's just reviewing cases after the fact review your colleagues' cases, and then as you do more and more of that.

[SPEAKER_02]: The American Society of Ecocardiography, the ANC has some tremendous guidelines on their website. [SPEAKER_02]: It's a free resource that can really help you take a jump in your knowledge in addition to finding textbooks that can walk you through more advanced echo concepts. [SPEAKER_01]: Fabulous.

[SPEAKER_01]: All right. [SPEAKER_01]: That's all amazing. [SPEAKER_01]: Anything else you want to make sure people know before we move on? [SPEAKER_02]: Now, I think that's it, my goal in trying to share all this is to communicate just how valuable TE is to the period of clinician. [SPEAKER_02]: That's the point in my podcast is to be able to show people the ways it can be beneficial in their clinical care even tomorrow that they can make a big difference in patient care.

[SPEAKER_02]: The more they learn, the more they advance their skills in this. [SPEAKER_02]: And then it can be done in a simple way or in a high yield way. [SPEAKER_01]: fabulous. [SPEAKER_01]: Well, this has been great. [SPEAKER_01]: Let's turn to the part of our show. [SPEAKER_01]: We make random recommendations.

[SPEAKER_01]: Andreas, what would you recommend the audience check out for fun? [SPEAKER_02]: Yes, so I think my random recommendation would be that if you have never been a US national park person, I would encourage making it your next vacation destination, especially considering some of the places in the western United States, California, Utah, Arizona.

[SPEAKER_02]: So my family, we have a goal to go to all of them together. [SPEAKER_02]: That's my wife and three young kids. [SPEAKER_02]: We've been to about 25 of the 63 parks as a family and there's just something that we find [SPEAKER_02]: finding fresh air, beautiful surroundings in the country, and maybe even no internet or sell service, that's just good for the soul.

[SPEAKER_02]: I know it's good for mine, so I think that's my random recommendation. [SPEAKER_01]: That's awesome. [SPEAKER_01]: Do you have a favor amongst the 25 you've been to? [SPEAKER_02]: It's got to be Yosemite in California, there's just something the magnitude of the sites there is just unparalleled in my opinion.

[SPEAKER_01]: Yeah, Yosemite is really something. [SPEAKER_02]: Have you been to Yellowstone? [SPEAKER_02]: I've been to Yellowstone and I've paired it with a trip to Galatia, which is probably the number two on my list as well. [SPEAKER_01]: Fabulous. [SPEAKER_01]: Yeah, I want to do more. [SPEAKER_01]: I want to do more.

[SPEAKER_01]: That's a great recommendation. [SPEAKER_01]: Well, I'm going to recommend a much less lofty, but enjoyable recommendation for a book that I'm in the middle of now. [SPEAKER_01]: So I can't speak to how it ends, but I'm really enjoying it. [SPEAKER_01]: It's called Buckeye by Patrick Ryan.

[SPEAKER_01]: It's a novel that is really. [SPEAKER_01]: sweeping. [SPEAKER_01]: It starts in the end of World War II and kind of deals with two different families as their lives are intertwined throughout the next 50 years or so. [SPEAKER_01]: It's really well written. [SPEAKER_01]: It was recommended by the New York Times as one of their best books of this past year.

[SPEAKER_01]: And it's been a good read so far. [SPEAKER_01]: So I recommend checking it out. [SPEAKER_01]: Buckeye by Patrick Ryan. [SPEAKER_01]: All right. [SPEAKER_01]: Andreas, this has been great. [SPEAKER_01]: Thanks so much for coming on the show. [SPEAKER_02]: Absolutely. [SPEAKER_02]: Well, thank you so much for having me.

[SPEAKER_01]: All right, hopefully you got as much out of that as I did. [SPEAKER_01]: That was really fantastic. [SPEAKER_01]: Let us know what you thought. [SPEAKER_01]: Go to the website,acrack.com where you can leave a comment. [SPEAKER_01]: Others can learn from what you have to say. [SPEAKER_01]: If you are a fan of the show, you can follow us.

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[SPEAKER_01]: Thanks so much for all you do. [SPEAKER_01]: Our original ACRAG music is by Dr. Dennis Quow. [SPEAKER_01]: You can check out his website at studymusicproject.com. [SPEAKER_01]: All right, that is it for today. [SPEAKER_01]: For the ACRAG podcast, I'm Jed Wolpa. [SPEAKER_01]: Thanks for listening.

[SPEAKER_01]: Remember what you're doing out there every day is really important and valued.

Episode 337: TEE for the non-cardiac Anesthesiologist with Andreas Plackis

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