Perioperative echocardiography-guided hemodynamic therapy in high-risk patients: a practical expert approach of hemodynamically focused echocardiography

Abstract

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO₂) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO₂. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.

Keywords: Echocardiography; Hemodynamic optimization; Monitoring; Perioperative.

Fig. 1

Pericardial tamponade. a Highlighted in yellow, via 4C view. b Without highlights, via 4C view. c Highlighted in yellow, via PLAX view. d Without highlights, via PLAX view. e Highlighted in yellow, via PSAX view. f Without highlights, via PSAX view

Fig. 2

Concentric hypertrophy. a End diastolic, with endocardium highlighted in yellow and epicardium highlighted in blue, via PSAX view. b End diastolic, without highlights, via PSAX view. c End systolic, with epicardium highlighted in blue, via PSAX view. d End systolic, without highlights, via PSAX view

Fig. 3

Right convex interatrial septum. a Septum highlighted in yellow, via 4C view. b without highlights, via 4C view

Fig. 4

Inferior vena cava via TTE. Marked in yellow is the diameter with measurements given

Fig. 5

Right heart dilation. a with right ventricle highlighted in yellow and left ventricle highlighted in blue, via 4C view. b without highlights, via 4C view. c with right ventricle highlighted in yellow and left ventricle highlighted in blue, via PLAX view. d without highlights, via PLAX view. e with right ventricle highlighted in yellow and left ventricle highlighted in blue, via PSAX view. f without highlights, via PSAX view

Fig. 6

TAPSE, with tricuspid annulus excursion marked in Motion-Mode

Fig. 7

Left ventricular dysfunction. a End diastolic phase, left ventricle highlighted in yellow, via 4C view. b End diastolic phase, without highlights, via 4C view. c Dilation in end systolic phase, left ventricle highlighted in yellow, via 4C view. d Dilation in end systolic phase, without highlights, via 4C view

Fig. 8

Mitral valve regurgitation, with doppler, via 4C view

Fig. 9

Continouous wave Doppler across the aortic valve to measure the velocity time integral