CSA Online First

CSA Online First is a weekly blog featuring insights from CSA members themselves.

Edited by Emily Methangkool, MD, MPH, with contributions from CSA’s Committee on Professional and Public Communications, Online First is a place where knowledge and opinion from any one of our 3200 plus physician-anesthesiologist members can be shared, discussed and deliberated to advance the specialty of anesthesiology, the practice of medicine and society in general.

"Better solutions to difficult problems are usually made when all sides are heard."

Steven Goldfien, MD

 

Perioperative Ultrasound Training in Anesthesiology: Challenges and New Opportunities

by
  • Ortner, Clemens, MD, MS, DESA
| Nov 07, 2022

clemens ortnerAs ultrasound machines have become smaller, more affordable, and more widely available, sonography is no longer a skill confined to cardiologists and radiologists. Point-of-Care Ultrasonography (POCUS) has become an effective tool to guide invasive procedures and perioperative decision making. The use of focused cardiac ultrasound can help identify cardiac pathology missed by clinical exam alone and help create differential diagnoses in the hemodynamically unstable or acutely dyspneic patient. By applying focused cardiac ultrasound, a group of POCUS-pioneers from Denmark revealed unexpected cardiopulmonary pathology in up to 27% of patients undergoing urgent surgical procedures leading to a change in anesthesia technique and supportive perioperative care. Using POCUS during in hospital rapid response has been shown to facilitate diagnosis, shorten time to first treatment intervention and, most importantly, has been associated with significantly lower hospital mortality.  

Bedside gastric ultrasonography has become a valuable tool for the evaluation of gastric contents when the risk of aspiration is uncertain or unknown. In patients presenting with conflicting information regarding their NPO status, gastric ultrasound has been shown to change timing and anesthesia technique resulting in overall decrease of surgical delays. Airway ultrasound can help predict a difficult airway, identify the cricothyroid membrane, differentiate between tracheal or bronchial intubation, or facilitate laryngeal nerve blockade.

The Accreditation Council for Graduate Medical Education (ACGME) introduced basic aspects of cardiopulmonary and vascular sonography as a mandatory requirement for anesthesia training in 2018.  Furthermore, fundamental knowledge of transthoracic echocardiography (TTE) became part of the content outline for the basic and advanced American Board of Anesthesiology (ABA) exams, with pulmonary and gastric ultrasound being added to the outline by 2023 and 2024, respectively. As a result, many anesthesia residency programs have implemented POCUS into their curricula over recent years.

While this is excellent news for current trainees, anesthesiologists who graduated before POCUS may need additional training. The American Society of Anesthesiology (ASA) has launched the “Diagnostic POCUS Certificate Program." This program has been created for anesthesiologists to set standards in our specialty when defining mastery in point-of-care cardiopulmonary, gastric and abdominal ultrasound. Many modules of the training program can be completed online. To support learners, a variety of E-learning resources have become available over recent years, some offered for free (www.pocuseducation.com, www.pocus101.com, www.pie.med.utoronto.ca/POCUS), or minimal charge (www.usabcd.org, 123sonography.com). However, an important component of developing POCUS-skills lie in hands-on training, which can be a particular challenge for anesthesiologists practicing in a non-academic setting. There may be difficulties in finding a mentor to review performed scans and in completing hands-on workshops on basic skills in image acquisition in a timely manner. In California, most of these courses are provided in academic settings open to faculty of the same organization only, frequently leaving practitioners in private practice to travel to national or international meetings as the only option.

The Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, in collaboration with the CME office of Stanford School of Medicine, are proud to offer one and a half day workshops with discounted rates for CSA-members in perioperative POCUS, tailored to the needs of practitioners in the non-academic setting (https://stanford.cloud-cme.com/pocus2023). Besides providing theoretical and hands-on training in cardiopulmonary, gastric, airway and abdominal ultrasound, the courses will allow attendees to meet potential mentors that can help support long-term mastery in perioperative POCUS. Hopefully, as attention grows around POCUS, future opportunities will arise for anesthesiologists in California to practice and hone their skills.

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