Practice Guidelines for Perioperative Transesophageal Echocardiography

Abstract

* Developed by the American Society of Anesthesiologists Task Force on Perioperative Transesophageal Echocardiography: Daniel M. Thys, M.D., Chair, New York, New York; Martin D. Abel, M.B.B.Ch., Rochester, Minnesota; Robert F. Brooker, M.D., Wausau, Wisconsin; Michael K. Cahalan, M.D., Salt Lake City, Utah; Richard T. Connis, Ph.D., Woodinville, Washington; Peggy G. Duke, M.D., Atlanta, Georgia; David G. Nickinovich, Ph.D., Bellevue, Washington; Scott T. Reeves, M.D., Charleston, South Carolina; Marc A. Rozner, Ph.D., M.D., Houston, Texas; Isobel A. Russell, M.D., San Francisco, California; Scott C. Streckenbach, M.D., Boston, Massachusetts; Pamela Sears-Rogan, M.D., Washington, DC (American Society of Echocardiography); and William J. Stewart, M.D., Cleveland, Ohio (American College of Cardiology).PRACTICE Guidelines are systematically developed recommendations that assist the practitioner and the patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.This update includes data published since the Practice Guidelines for Perioperative Transesophageal Echocardiography were adopted by the ASA and the Society of Cardiovascular Anesthesiologists in 1995 and published in 1996.1For these Guidelines, perioperative transesophageal echocardiography (TEE) refers to TEE performed on surgical patients before, during, or immediately after surgery, including the critical care setting. Evidence of effectiveness is discussed relative to specific settings where perioperative TEE is customarily used (e.g. , cardiac surgery, noncardiac surgery, and critical care).The purposes of these Guidelines are (1) to assist the physician in determining the appropriate application of TEE and (2) to improve the outcomes of surgical patients by defining the utility of perioperative TEE based on the strength of supporting evidence.These Guidelines focus on the application of TEE in surgical patients and potential surgical patients in the setting of cardiac surgery, noncardiac surgery, and postoperative critical care. The Guidelines do not apply to the assessment of nonsurgical patients or to postdischarge follow-up assessment of surgical patients.The Task Force believes that physician proficiency in the use of perioperative TEE is of paramount importance due to the risk of adverse outcomes resulting from incorrect interpretation. The Guidelines do not address training, certification, credentialing, and quality assurance, which are addressed elsewhere.2–5These Guidelines are intended for anesthesiologists and other physicians (e.g. , cardiologists, surgeons, and intensivists) who use TEE in the perioperative setting. Recommen- dations to perform TEE are not applicable when the procedure cannot be performed properly or safely nor do they apply when TEE equipment or skilled examiners are unavailable. The recommendations in this report are based on consideration of the risk benefit ratio for individual patients.The ASA and Society of Cardiovascular Anesthesiologists jointly appointed a task force of 13 members, including anesthesiologists in both private and academic practice from various geographic areas of the United States, two cardiologists (one representing the American College of Cardiology and the other representing the American Society of Echocardiography), and two consulting methodologists from the ASA Committee on Standards and Practice Parameters.The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to TEE were reviewed and evaluated. Third, expert consultants were asked (1) to participate in opinion surveys on the effectiveness of TEE imaging and (2) to review and comment on a draft of the Guidelines developed by the Task Force. Fourth, opinions about the Guidelines recommendations were solicited from a sample of active members of the ASA who personally perform TEE as a part of their practice. Fifth, the Task Force held an open forum at a major international meeting†to solicit input on its draft recommendations. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to