Imagine administering anesthesia without a pulse oximeter. Does it terrify you? For the vast majority of CSA members, the thought of conducting an anesthetic without pulse oximetry would never even cross their minds. Indeed, the invention of the pulse oximeter in 1972 transformed the practice of anesthesia and by improving safety, paved the way for innovative surgical achievements never before thought possible.
In the past 45 years, despite tremendous advancements in medical technology, no other modality has been able to match the impact on patient safety as the pulse oximeter. So how do we demonstrate our commitment to patient safety? How do we promote high quality care?
Although not a new modality, ultrasound is being increasingly used in the perioperative setting to assess patient status in a variety of settings, particularly in time-sensitive or critical situations. The Society of Cardiovascular Anesthesiologists published a “Call to Action” paper in Anesthesia and Analgesia last year (Mahmood F, Matyal R, Skubas N, et al. Perioperative ultrasound training in anesthesiology: a call to action. Anesth Analg. 2016;122:1794–1804) , encouraging anesthesiologists to take the lead on perioperative ultrasound. We are well-positioned to expand the use of ultrasound; we already use it for central line placement, arterial line placement, difficult IV access and regional nerve blocks, and we work in acute care settings where rapid diagnosis and evaluation is critical.
Traditional ultrasound machines are ubiquitous in the hospital, with use in nearly every department. However, point-of-care ultrasound machines have now become affordable and portable, with models that can fit in a white coat or scrub pocket.
Some ways that perioperative, point-of-care ultrasound can improve patient safety include:
- Scanning for bladder distension
- Assessment of gastric volume
- Detection of pneumothorax
- Confirmation on tracheal intubation
- Predication of difficult extubation
- Evaluation of pleural effusions and guidance for thoracentesis
- Detection of pericardial effusion or tamponade
- Evaluation of cardiac fluid status and ventricular function, and
- Detection of intraperitoneal fluid or hematoma.
Perioperative ultrasound can provide crucial information that allows anesthesiologists to diagnose and intervene quickly. (Anesthesia & Analgesia: March 2017 - Volume 124 - Issue 3 - p 709–711)
Although the ER has used ultrasound in the evaluation of trauma patients for decades, appreciation of its perioperative utility has been a more recent development. A new algorithm created by anesthesiologists from Loma Linda University, UCLA, and UC Irvine: FORESIGHT (Focused, Perioperative Risk Evaluation Sonography, Involving GastroAbdominal, Hemodynamics, and Trans-Thoracic Ultrasound) can be found at www.FORESIGHTultrasound.com. This is a phenomenal resource, with lectures, slides, and podcasts on the nuts and bolts of using ultrasound in the perioperative setting.
It is imperative that anesthesiologists continue to engage in and improve patient safety. We are the first specialty to have our own patient safety foundation, and have continued to be at the forefront of the patient safety movement. We should continue to advance perioperative ultrasound and actively engage our trainees to do more, learn more, and advance with technology.
The Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Anesthesiology (ABA) have identified ultrasound as a key milestone in resident education. All residency programs must integrate perioperative ultrasound into their core curriculum. While many programs already have great courses in tranesesophageal echocardiography, they should expand to transthoracic echocardiography and Point of Care techniques.
But how do those of us already in practice get up to speed? Although I only graduated residency in 2012, I did not have exposure to these uses of perioperative ultrasound. To remain relevant, we must acquire new skills and change our practice as appropriate. Consultation of online resources such as www.FORESIGHTultrasound.com can be helpful, however, live instruction is necessary. Luckily there are numerous workshops held throughout the country.
For CSA members who wish to improve their skill set, the Loma Linda University Department of Anesthesiology and the UCLA Department of Anesthesiology and Perioperative Medicine are hosting a Perioperative and Acute Care Ultrasound Workshop on September 9 and 10 at the Hyatt Regency Huntington Beach Resort and Spa. Key topics include assessment of volume status, evaluation of pulmonary and cardiac function, advanced vascular access, perioperative point of care ultrasound, and regional anesthesia. Eighteen topics will be covered with 6 hours of hands-on training. More information can be found at www.pocuseducation.com.
Patient safety should always be the primary focus of our practice. We now have accessible, affordable, portable tools to rapidly diagnosis and treat acute patient conditions. All CSA members should look into acquiring new skills in ultrasound. This is how we provide safe, high quality care; this is how we provide value-based care.