24 hour TEE service

[dr_bigmac]

I frequently come to this forum to follow the interesting discussions. In addition this forum is a great place to find pearls of wisdom and guidance.
Because I'm just starting out on my internship/residency (in the Netherlands!) this year, I haven't had the nerve to post alot. Leaving the discussions to the more experienced.

I've recently started a study/research project concerning TEE's. TEE's aren't employed as widespread as in the states but there are several accreditation possibilities (ACTA/NBE, EACTA and DGAI). The criteria of accreditation are mostly variations on the ASA/SCA layout for accreditation.

Though the criteria are virtually the same, the goal is to create a certification process which allows participants to use TEE in all hospital patients (surgical and non-surgical).

Here in the Netherlands we'd like to create a 24 hour TEE service providing coverage to all hospital patients. Here we're all convinced it would improve patient care. But for my research I need to survey reasons for setting up such a service (or not) in a multiple choice format. I've thought some up but it seems I'm still missing something.

Could someone help me on the pro's and con's of a 24 hour TEE service?

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[militarymd]

24 hour TEE service?? Looking for what?

 

[Qtip96]

really only makes sense for a level I-II trauma center, where timely TEE for suspected aortic disruption/dissection is necessary. most other studies can be done semi-urgently in the AM, addressed by transthoracic study, or CT/MRI.

 

[dr_bigmac]

The general consensus here is that a team of physicians trained in TEE providing a 24 hour coverage would expedite patient management in the ICU/ventilator dependent population.
Seeing that TEE trained ICU personel is scarce (at least in Europe) having a cadiac anesthesiologist on hand could be helpfull. Possibly for monitoring of haemodynamics or post-op CT patients.

 

[Qtip96]

The general consensus here is that a team of physicians trained in TEE providing a 24 hour coverage would expedite patient management in the ICU/ventilator dependent population.
Seeing that TEE trained ICU personel is scarce (at least in Europe) having a cadiac anesthesiologist on hand could be helpfull. Possibly for monitoring of haemodynamics or post-op CT patients.

sorry, but it's bollocks.

 

[dr_bigmac]

Look, I'm only a medstudent starting anesthesia residency this year. I don't have any experience in the ICU except what I experienced during my six weeks of anesthesia rotation. So if my supervisor is telling me something that doesn't make sense to you, I would like to know why!

 

[AJM]

The general consensus here is that a team of physicians trained in TEE providing a 24 hour coverage would expedite patient management in the ICU/ventilator dependent population.
Seeing that TEE trained ICU personel is scarce (at least in Europe) having a cadiac anesthesiologist on hand could be helpfull. Possibly for monitoring of haemodynamics or post-op CT patients.

I can't think of a single situation I've had in the ICU where a middle-of-the-night TEE would have helped my management or changed my management in any way. If you truly need an echo in the middle of the night, a TTE is sufficient. If you need to monitor hemodynamics, you can use a central line or a PA catheter, or once in a while slap on an ultrasound for a transthoracic view of the heart. I don't see how a TEE would add anything. In the few situations where a TEE might be useful, this can typically wait to be done in the morning.

I agree that maybe it would be useful in the ED of a trauma center, but I can't think of any other potential application for this.

 

[nimbus]

Isn't this what cardiologists are for? Granted they are not in house but they are on call 24/7 for urgent PCIs and do occasionally do urgent echos as well.

 

[DreamMachine]

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[Laryngospasm]

I recall one event of decreasing hemodynamics on a post/op CAB pt, who was too obese for 2D to see anything, we did do a tee in the middle of the night on that pt, and they were returned to the OR for tamponade. Only one I can think of though.

 

[Qtip96]

Isn't this what cardiologists are for? Granted they are not in house but they are on call 24/7 for urgent PCIs and do occasionally do urgent echos as well.

few cardiologists are level III ECHO certified and know what the heck they are doing with a TEE probe. COCATS requirements for general cardiologists and level I training are for transthoracic studies only. the bulk of TEE experience by cardiac anesthesiologists are those performed during CABG or valve surgery, and with little to no experience in evaluating aortas associated with acute trauma. sure there may be an obvious disruption, but identifying an intimal tear can sometimes be a tricky finding.

what i'm trying to say is that in the extremely rare case that you might need an emergent middle-of-the-night TEE, you'd want a level III certified echocardiographer performing the study. like i said, this scenario rarely surfaces outside level I - II trauma centers. most other needs can be satisfied by clinical judgment, TTE, CT, or MRI.

 

[militarymd]

few cardiologists are level III ECHO certified and know what the heck they are doing with a TEE probe. COCATS requirements for general cardiologists and level I training are for transthoracic studies only. the bulk of TEE experience by cardiac anesthesiologists are those performed during CABG or valve surgery, and with little to no experience in evaluating aortas associated with acute trauma. sure there may be an obvious disruption, but identifying an intimal tear can sometimes be a tricky finding.

what i'm trying to say is that in the extremely rare case that you might need an emergent middle-of-the-night TEE, you'd want a level III certified echocardiographer performing the study. like i said, this scenario rarely surfaces outside level I - II trauma centers. most other needs can be satisfied by clinical judgment, TTE, CT, or MRI.

Doesn't the "level III" designation mean someone qualified to be the director of an echo lab.....ie extensive, extensive, extensive training....the kind of guys at fellowship programs?

Do you really need "level III" designation to provide the TEE services already mentioned?

 

[Qtip96]

I recall one event of decreasing hemodynamics on a post/op CAB pt, who was too obese for 2D to see anything, we did do a tee in the middle of the night on that pt, and they were returned to the OR for tamponade. Only one I can think of though.

we usually do not perform CABGs on patients over 300lbs.

getting a TTE window for pericardial effusion is the easiest window to get. granted, on a fat person, getting parasternal or apical views can be tough, but i have yet to ever fail to obtain a transthoracic window for pericardial effusion on a patient. there was always a subxyphoid window somewhere. granted, if there is a TEE probe available, a complete study takes me 15min rather than struggling with a poor quality partial transthoracic study.

 

[dr_bigmac]

I recall one event of decreasing hemodynamics on a post/op CAB pt, who was too obese for 2D to see anything, we did do a tee in the middle of the night on that pt, and they were returned to the OR for tamponade. Only one I can think of though.

Post-op cardiothoracic patients being ventilated in de ICU seem to me to be the most likely to require an emergency TEE if problems occur.
For haemodynamics I think a lot of patients can be managed by just using a PAC or Central Line. But maybe TEE can add to the information? Normal PAC pressures don't always mean nothing is going on...

I'm interested in knowing how often anesthesiologists use perioperative TEE? What type of non-cardiac cases?

 

[Qtip96]

Doesn't the "level III" designation mean someone qualified to be the director of an echo lab.....ie extensive, extensive, extensive training....the kind of guys at fellowship programs?

Do you really need "level III" designation to provide the TEE services already mentioned?

all general cardiology fellows need to fulfill level I, and only requires numbers for transthoracic procedures (although some exposure to TEE is included in most programs).

you need at least level II to perform TEEs autonomously. only 3 additional months and 75 additional procedures, of which the TEE experience usually calls for at least 25 esophageal intubations and 50 supervised studies. i performed >75 TEEs in my fellowship, and (being honest here) i don't consider myself fully qualified to feel confident in the trauma setting.

you are right in that level III is designed for people wanting to direct ECHO labs, but the actual numeric criteria is surprisingly easy (9 additional months, 150 additional procedures). the attendings in my institution who take call for TEE are generally level III cert. if it were my (or my loved one's) ass on the line, i would want one of them doing (or supervising) the study, and not someone like me. generally, level II cert is considered adequate, but the numeric criteria are woefully insufficient for complicated real-world scenarios, i think.