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Reply
- Ming-Jiuh Wang (14 March 2006)
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Appropriateness of TOE during cardiac arrest
- saurabh nagpaul (13 March 2006)
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Reply
- Ming-Jiuh Wang (6 March 2006)
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TOE during cardiac arrest
- Malcolm A Broom (10 February 2006)
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Ming-Jiuh Wang, Cardiovascular Anesthesiologist National Taiwan University Hospital and National Taiwan University College of Medicine
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The placement of the TOE probe take only less than 30 seconds to one minute in experienced hands. Furthermore, the cardiac resuscitation was continued since the placement of TOE probe does not hinder the cardiac massage in any patient. On the contrary, the use of transthoracic echocardiography which may be performed by a cardiologist who was usually not available at the time of resuscitation and it is not easy to be done during cardiopulmonary resuscitation. In our patient of caerean section, the blood loss was not evident from the operative field, the TOE probe was placed to find out the etiology. Although we could not ascertain whether the wall motion abnormality was chronic or acute, the TOE finding did provide the clues for the diagnosis. The rapid impression of regional wall motion abnormality and the exclusion of other causes of cardiac arrest is important in the first few minutes in helping further management of the patients. Conflict of Interest:None declared |
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saurabh nagpaul, senior house officer,anaesthetics Hull Royal Infirmary,Hull
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Dear editor, I read this article with great interest and I appreciate the fact that TOE is a good tool for finding the cause of sudden cardiac arrest.But there are a few points I would like to stress upon. Firstly, is it appropriate to waste those precious few minutes which are utilised for insertion of TOE probe? I would rather use those minutes for continuing cardiopulmonary resuscitation.Secondly,we have better reliable clinical signs to find out the cause of the arrest.For example - hypovolemia leading to arrest in case of caesarian section can be easily made out by looking at the amount of blood loss,monitoring blood pressure and pulse.At the same time if it is the myocardial infarction which has caused the arrest,then the management of arrest and post arrest remains the same whether you have used TOE or not.Also,how sure we can be in saying whether the ventricular wall or septal wall changes are acute or chronic? I feel having a transthoracic echocardiography as a diagnostic tool would be much quicker ,less invasive and much safer option. Conflict of Interest:None declared |
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Ming-Jiuh Wang, Doctor, Cardiovascular anesthesiologist Dept Anesthesiology, Natl Taiwan Univ Hospital and National Taiwan University College of Medicine
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Dear editor: We agree that the TOE is not helpful for diagnosing cardiac arrest caused by the 4H’s and 4T’s. However, in the clinical scenario of cardiac arrest during non-cardiac operations, the preoperative assessment would help to exclude most of these H’s and T’s. In addition, the oxygen status, the body temperature and the electrolyte concentration would be either closely monitored or easily diagnosed with modern intraoperative monitoring devices. The most difficult part in the management of patients suffering from unexpected cardiac arrests is to exclude the possibly correctable conditions e.g. aortic dissection, pulmonary embolism or hypovolemia in the first few minutes. The existence of regional wall motion abnormality in our series suggested the diagnosis of acute myocardial infarction and is helpful for the anesthesiologists to treat these patients with more confidence. The TOE is commonly available in the operating theater in hospitals having cardiac operations. Although it is not easily available within several minutes in the general hospital setting, however, we did use TOE to diagnose pulmonary embolism after gynecological operations and the patient was successful rescued with emergent pulmonary embolectomy(1). In fact, TOE was successfully used to diagnose the etiology of both inside and outside hospital cardiac arrest in the emergency service(2). The advantage of TOE as compared with transthoracic echocardiography is that the effective resuscitation could be done simultaneously and did not interfere TOE examination and the TOE examination can be performed without interfering ongoing resuscitation. Sincerely Yours, Ming-Jiuh Wang References: 1. Shen-Kou Tsai, Ming-Jiuh Wang, Wen-Je Ko, and Shua-Juen Wang .Emergent bedside transesophageal echocardiography in the resuscitation of sudden cardiac arrest after tricuspid inflow obstruction and pulmonary embolism. Anesth Analg 1999;89:1406-8 2. van der Wouw PA, Koster RW, Delemarre BJ, de Vos R, Lampe- Schoenmaeckers AJ, Lie KI. Diagnostic accurany of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol 1997;30:780-3 Conflict of Interest:None declared |
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Malcolm A Broom, SHO Anaesthetics Glasgow Royal Infirmary
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Editor – I was interested to read the study by Lin et al, using TOE in unexpected cardiac arrest during non-cardiac surgery. However, I wondered how much this intervention truely improves outcome. The best chance of surviving cardiac arrest is by identifying and treating the “4 H’s and 4 T’s” representing reversible causes1.Of these, TOE is neither helpful nor necessary to diagnose Hypoxia, Hypothermia, Hyper/Hypokalaemia, Tension pneumothorax or Toxic/Therapeutic disturbance. Of the remaining, there is likely to be a clue to the cause from the clinical situation. 3 of the 10 patients were undergoing bypass grafting for occlusive arterial disease of the lower limbs and it is not surprising to learn that their arrests were secondary to MI with underlying coronary arterial disease in the 2 diagnosed cases (the third case is reported as “unknown” cause). Similarly 2 patients undergoing major orthopaedic procedures suffered PE. Again, this would be an immediately obvious cause to spring to mind in the situation, although certainly the use of TOE for definitive diagnosis here is evident. It would also be difficult for hospitals to provide the service described - TOE in theatre within 5 minutes of arrest and occurring on less than 2 occasions per year or approximately 1/12,500 patients, according to this study. With 3 deaths from the 10 cases, the “numbers needed to treat”, become even higher. Finally, there was no mention of how the ongoing resuscitation efforts interfered with the ability to perform effective echocardiography, and more crucially, If TOE interfered with effective resuscitation. It would be interesting to study outcomes using TOE as described here against conventional ALS guidelines without TOE to assess if this intervention truly improves outcome. 1. Resuscitation Guidelines 2005, Resuscitation council (UK) M. Broom Glasgow, UK Conflict of Interest:None declared |
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