He doesn’t need a bedside echo without an official report by someone not board certified in cardiology.
I agree with this. I think bedside TTE is a valuable skill to have, and I'll do it for emergency or urgent cases as a POC test to give myself a little more information before doing the case, minutes later. It's a useful tool. What TTE in my hands is not, is an end run around appropriate preop workup in the weeks before elective surgery.
If a patient scheduled for elective surgery in two weeks has risk factors, symptoms, and a new LBBB, he goes to cardiology. And not just because I'm TEE boarded not TTE boarded and I'm anxious about medicolegal cover, but because it's the right thing for the patient. This patient may need intervention and the cardiologist, not me, is best suited to make that determination.
I don't want clearance from a cardiologist, I want a statement that the patient is optimized, and on top of that some objective echo/cath/stress test data is nice to have.
Bedside echocardiography can also avoid cancellation of surgery when a significant new heart murmur is detected.
... how often does this happen in your practice? I’ve never seen this.
I wouldn't turn a no-go into a go decision based on what I saw on a bedside TTE in holding. Our guidelines without it are sufficient. If you hear a loud murmur and the patient's functional status and symptoms don't justify canceling, you're going to do the case but maybe assume the worst and be careful. A bedside TTE can be useful there.
I guess it's conceivable that if I put a probe on someone and saw terrible AS or MS or an EF of 15 when I was expecting 60, I might turn a go into a no-go but it's hard to imagine there wouldn't be symptoms from the history.
I guess what I'm getting at is that I view bedside TTE as more of a reason to justify canceling if I get some vibe that all is not well, than to turn a cancel into a go.
A few weeks ago we had a case (not mine, I heard about it as the M&M coordinator) where a loud previously undocumented murmur was heard in preop holding on the day of surgery. They assumed it was AS and put in a preinduction a-line and proceeded cautiously. Patient crumped anyway and needed large doses of norepi and vaso to stabilize. They aborted, woke up, admitted. Postop workup showed a Hb of 4.something and a normal echo. It was just a hell of a flow murmur from the high CO and low viscosity. Maybe a bedside echo would've changed the plan from go to no-go by showing no valvular disease and prompting a search for another reason? I don't know. That's maybe a stretch. Maybe it would've reassured them enough not to do an a-line and the patient would've coded before the next q3min NIBP.
Anyway, bedside TTE in preop holding is outside our go/no-go decision making guidelines, and for me I think it's a nice source for supplemental information to do the case I was going to do anyway. I wouldn't use it to un-cancel a case I was going to cancel.
