Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Focus point-of-care echocardiography provides immediate and actionable information to clinicians caring for critically ill patients.
Speaker: Critical care clinicians commonly utilize trans-horacic echocardiography in the ICU as part of their point-of-care ultrasonography toolkit.
Speaker: Today there's a growing push to train intensivists and emergency medicine clinicians in using transesophageal echocardiography, TEE, for cardiac arrest and pre-array situations in the ICU and emergency department.
Speaker: Today's podcast episode will discuss TEE and cardiac arrest and shock.
Speaker: Our guest is Dr. Sarah Nikravan, a cardiothoracic anesthesia critical care physician with training in advanced perioperative echocardiography.
Speaker: She's an associate professor of cardiothoracic anesthesiology and critical care medicine at the University of Washington Medical School and practices at the University of Washington Medical Center.
Speaker: In addition, Dr. Nikravan is vice chair for education and director of point-of-care ultrasound in the Department of Anesthesiology and Pain Medicine.
Speaker: She is recognized as an expert and master educator in critical care, perioperative echocardiography, and point-of-care ultrasound.
Speaker: She has authored numerous peer-reviewed papers and is the guidelines co-chair of the Society of Critical Care Medicine Guidelines on Adult Critical Care Ultrasonography, Focus Update 2024, recently published in Critical Care Medicine.
Speaker: Sarah, welcome to Critical Matters.
Speaker: Oh my gosh, Sergio, thank you so much for inviting me.
Speaker: I was listening to that and wondering, who is that person?
Speaker: That person, me?
Speaker: Thank you for that lovely intro.
Speaker: Thank you for coming.
Speaker: This is a topic that I've heard you lecture on and you're very passionate and knowledgeable about, but I do think
Speaker: as we were discussing earlier, that trans-horacic echocardiography and point-of-care ultrasound obviously are permeating and quite endemic, I think, today in critical care and emergency practices.
Speaker: But this is kind of like the next step for many people, and I think it's quite interesting.
Speaker: So from your perspective, maybe as a starting point, you could just tell us why should intensivists care about TEE?
Speaker: Well, you know, as you know, as an intensivist, we take care of the sickest patients.
Speaker: And often their conditions, the way that they present, make it challenging for us to collect data sometimes.
Speaker: You know, they're unconscious or in extremis.
Speaker: And they really don't read the textbook.
Speaker: You know, usually they have multiple disease processes that are going on at once.
Speaker: And it can limit our, you know, understanding of physiology, the interplay of physiology and the data that we collect.
Speaker: I think about, for example, challenging situations when patients present with lung hyperinflation or subcutaneous emphysema or anisarca.
Speaker: They could have chest trauma.
Speaker: They could have maybe post-cardiac surgery.
Speaker: They could have drains everywhere and ventricular assist devices.
Speaker: Some of them may even come to us with open chest.
Speaker: And that really limits patients.
Speaker: our ability to do certain things, such as, for example, transthoracic echo or surface imaging.
Speaker: And that is where I think transesophageal echocardiography can really come into play.
Speaker: We're seeing more and more evidence to support the utility of TEE, particularly in arrest patients for guiding things such as hand positioning to improve the efficacy of CPR,
Speaker: and for the return of spontaneous circulation, and also to help us narrow our differential diagnosis and treat patients.
Speaker: So I think, you know, we should really care about this topic because TEE gives us an ability to see into the patient in a way that's much more clear with better imaging resolution than surface imaging resolution.
Speaker: So, yeah, so I think, you know, this is within our capability to do it.
Speaker: And there is some evidence to really support that it provides us with some better data.
Speaker: Excellent.
Speaker: So as we start our discussion, maybe you could point out to us some of the main differences between transesophageal echocardiography and transthoracic echocardiography in the context of the ICU.
Speaker: And that I would include, I mean, applications, pros and cons, and maybe even how do we achieve competence for this?
Speaker: And what are some of the differences that you see at a high level as somebody who uses both?
Speaker: Yeah, well, you know, of course, transthoracic echo and transthoracic imaging is non-invasive and has really become more readily accessible in the ICU because we have a lot of point-of-care ultrasound devices now kind of at our disposal.
Speaker: And some of this has been because they've become less expensive and they're often being used as a standard of care for certain invasive procedures such as vascular access or
Speaker: potentially thoracentesis, paracentesis.
Speaker: And now these devices are being really sold as point of care devices.
Speaker: So they are often coming with all three probes.
Speaker: You know, you're getting the cardiac probe, the abdominal probe, the vascular probe.
Speaker: And the difference, it kind of from that system standpoint, is the TEE is invasive, and that brings its own challenges.
Speaker: I think there is a lot of fear of doing harm to patients when deploying TEE.
Speaker: an invasive procedure such as transesophageal echocardiography, in particular in our patient population where sometimes we have limited information about the patients or maybe a poor understanding of the presence of contraindications for the placement of a TE probe.
Speaker: I think that we're a bit more fortunate in the intensive care unit because we're not the initial gatekeepers for admission of patients in the hospital the way that our colleagues are in the emergency department, meaning that typically they come to us with a little bit more information than our colleagues in the ED might get.
Speaker: But I think the big kind of functional differences are that undoubtedly transesophageal echocardiography has superior imaging resolution.
Speaker: It really gives us direct access to the heart without any interference of the ribs, the chest wall, the lungs.
Speaker: And we do have data to support that in our patient population,
Speaker: particularly in patients on mechanical ventilation.
Speaker: TE can provide really meaningful clinical information in up to 50% of those patients, which oftentimes you just can't get images on with surface imaging.
Speaker: And it can also provide unexpected diagnoses that can be missed with TE.
Speaker: And the data that we have is that in about the studied cases we have in about 40% of the time, we're getting unexpected diagnoses from using transesophageal imaging that were missed with transthoracic echo.
Speaker: So that's pretty, I think, remarkable and was a real motivator for me to kind of explore a little bit more in this space.
Speaker: The other, I think, big difference is that, you know, particularly when it comes to cardiac arrest, there have been some varied studies that have shown that surface imaging, transthoracic echo, when it's incorporated into ACLS, has prolonged the interruptions of chest compressions, which we know is probably the most important thing, right, when you're doing resuscitation.
Speaker: particularly when it's being deployed outside of some sort of regimented protocol.
Speaker: So there are these protocols like the FEAR protocol or the FEAL protocol that show how to incorporate TTE into the ACLS algorithm.
Speaker: But if people are not familiar with it and are just deploying it without having a system in place, it really can prolong interruptions and chest compressions.
Speaker: But TTE doesn't.
Speaker: You know, it can be in place during cardiac arrest and chest compressions can be ongoing the entire time without interfering with the care that's being done for the patient.
Speaker: It providing diagnostic imaging that, as we said, is superior.
Speaker: And also what we do know thus far from the studies that have been done is that, you know,
Speaker: We are seeing that trans-esophageal echo can really guide hand positioning for chest compression.
Speaker: So when we were putting our hands in the place that we've been putting them since the 50s, you know, nothing has changed, you know, in the normal place we've all been put to and told to put our hands.
Speaker: In many patients, this wasn't causing compression of the ventricles.
Speaker: It was causing occlusion of the left ventricular outflow tract or oftentimes of the ascending aorta.
Speaker: And when TE was used and hand positioning was kind of changed based on the imaging,
Speaker: We were seeing improvements in end tidal CO2 monitoring and also a return of spontaneous circulation.
Speaker: So that's one component of it.
Speaker: The other component is that the quality of chest compressions were able to be optimized.
Speaker: So, you know, maybe when we were doing chest compressions without having a real understanding of how the heart was being compressed, we weren't really doing a good job at the compressions.
Speaker: which was adjusted after the imaging was obtained.
Speaker: So those are the very kind of immediate practical components.
Speaker: And the other is just that, you know, you and I both know that many patients present in air quotes in PEA, but once
Speaker: you actually are able to see the heart and get an understanding of what's going on.
Speaker: You realize that it's a pseudo-PA situation that is oftentimes recoverable.
Speaker: And that is where I think the power of transesophageal echocardiography really lies.
Speaker: So, yeah, I hope that answered your question, you know, in regards to, I think, the differences between the two.
Speaker: I think it's easier for people to pick up a TTE probe because it's there,
Speaker: and it's not invasive, TE probes are invasive and they're also more expensive, so people don't have access to them a lot of times in the ICU, but maybe that should change based on the stuff that we're talking about here today.
Speaker: For sure.
Speaker: And I think an interesting aspect of this is that I think that the, like you said, the price of entry or there's less friction with doing a transthoracic because like you mentioned, more people feel comfortable with that.
Speaker: It's not invasive.
Speaker: You're just putting some gel on somebody's chest, right?
Speaker: And they're available everywhere.
Speaker: On the other hand, I think putting a TE usually involves the patient not intubated, sedation, and putting something that's invasive.
Speaker: It's a more less accessible, let's say, machine, more expensive maybe.
Speaker: And I think people are a little bit more...
Speaker: more intimidated by it, right?
Speaker: But my impression is that in critically ill patients, and I want your opinion on this, if I was starting from zero, I was going to learn echocardiography from zero, I probably would be able to obtain better images quicker with a TEE and intubated patient that was transthoracic.
Speaker: Is that true?
Speaker: Oh, 100%.
Speaker: I mean, it is so much easier to get imaging with TEE.
Speaker: And oftentimes you only need maybe one to four views to really get just a baseline understanding of what's going on, which is what's been kind of promoted with the whole resuscitative TEE protocols.
Speaker: Yeah, that is very true.
Speaker: And I think one of the biggest barriers of transthoracic imaging is image acquisition.
Speaker: It's hard to get good images.
Speaker: And that barrier kind of goes away with the TEE.
Speaker: It's much easier to see something that could be meaningful.
Speaker: I agree.
Speaker: And I think that the other thing that I have found in my experience is that it's hard to get good images.
Speaker: It's harder to get good images in critically ill patients on a vent.
Speaker: And it's hardest to get images in the middle of a code, right?
Speaker: I mean, it just gets progressively worse, right, for people who don't have a lot of experience.
Speaker: And I think that with a TEE, obviously, the biggest barrier other than having the equipment is the invasive nature of it.
Speaker: But if you already have an ET tube and you are either coding or about to code, I think that barrier becomes less of an issue, right?
Speaker: Absolutely.
Speaker: I mean, I tell you kind of a kind of a funny story.
Speaker: It may not be that funny, but I back in 2015, when I was at Stanford, I had a colleague through EM who asked me to help with a workshop.
Speaker: that they were having with another group of emergency medicine physicians.
Speaker: And they called me and said, hey, like, can you come and teach us transesophageal echo?
Speaker: You know, we're using it for resuscitation and emergency medicine.
Speaker: And I thought, what?
Speaker: But you don't know anything about like the contraindications of the
Speaker: putting in an echo probe in these patients.
Speaker: Like, what if they have esophageal injury or what if they have, you know, coagulopathy?
Speaker: Like, we could really do some harm in these patients.
Speaker: And the emergency medicine physician, I'll never forget it, he looked at me and he said, Sarah, the patients are dead.
Speaker: We are trying to help them not be dead.
Speaker: Exactly.
Speaker: And in that moment, I like...
Speaker: Looked at him, you know, and I thought, oh, my God, what a different perspective to have, you know, and I think that has been the huge, the biggest barrier for us because we as clinicians and practice providers like we don't want to hurt people.
Speaker: And would it be fair, Sarah, to say that in terms of when should an intensivist use a TEE versus a transthoracic to say we go to the TEE when we absolutely need certainty on certain images, right?
Speaker: That's very common when we're trying to figure out like postoperatively, immediately postoperatively, heart surgery, whether there's, I mean, some...
Speaker: kind of posterior effusion causing problems and we need a or or we have a patient with endocarditis who were or trying to rule out endocarditis we absolutely want to be sure you need those images that are provided by the trans esophageal and that usually is going to be maybe out of the realm of the intensivist but that's when you would go to te and for the intensivist when you have an intubated patient who's crashing
Speaker: If you have access to the TEE, especially if it's a cardiac arrest, you're just better off using the TEE.
Speaker: Is that correct?
Speaker: Yeah, I really think so.
Speaker: And I think we, like I said earlier, we have more information oftentimes about the backgrounds of our patients, you know, so that kind of takes away some of that fear in doing harm.
Speaker: But absolutely.
Speaker: I mean, because in a way, when you put the TE probe in place, and let's say you get your metesophageal four chamber view or your metesophageal long access view, your hands kind of become free.
Speaker: And you can have the imaging ongoing while you're doing other things to help the patient.
Speaker: And that is not typically the case with surface imaging, right?
Speaker: Like you have to continue to hold the probe there and struggle to get the image.
Speaker: So I agree with that fully.
Speaker: And I think to your point, it becomes important to know when you should go to TEE potentially as a first line patient.
Speaker: versus when you may be able to use transthoracic imaging and kind of avoid the invasive nature of transesophageal imaging.
Speaker: there are certain pathologies, like if you know the patient has emphysema everywhere or has ARDS and is like on a PEEP of 15, you know, or you're going to struggle.
Speaker: You're just, you can't get surface imaging when there's air in the chest or when the chest is open or whatever the case may be.
Speaker: So that's just an immediate, you know, transition to transesophageal imaging.
Speaker: Perfect.
Speaker: So as we move forward and eventually get to our clinical discussion, just I wanted to get a little bit of your perspective on the evolution of TEE to the hands of intensivists.
Speaker: So it looks like, I mean, you look historically at TEE, it obviously was the first of the domain of cardiologists.
Speaker: Then it really, because of the advantages you mentioned, became part of the cardiac anesthesia.
Speaker: toolkit, and now it's being pushed to intensivist and emergency medicine clinicians, or maybe not pushed, they're pulling towards themselves, right?
Speaker: Yeah, but in terms of these situations of either cardiac arrest, shock, or peri-arrest, now you probably, I assume, with your background, got trained during your cardiac anesthesia fellowship, right, as part of perioperative TEE.
Speaker: Yes, yeah.
Speaker: Yeah, I did.
Speaker: I mean, interestingly enough, I started my training actually in emergency medicine, which is probably how I ended up in this space because I fell in love with ultrasound there and saw back then like how much ultrasound was being used in the care of patients.
Speaker: I transitioned to anesthesiology and in the space of anesthesiology, I found it very interesting that surface imaging outside of being used for vascular access
Speaker: and maybe at the time some regional anesthesia was not really being deployed in the same way, and we had much more exposure to transesophageal imaging.
Speaker: in my anesthesia residency training.
Speaker: And then ultimately, of course, through cardiac anesthesia, that's where the bulk of it happened.
Speaker: And when I went back, you know, from anesthesia residency training, I went to a critical care medicine fellowship.
Speaker: There in that space, now I saw once again, point of care ultrasound with surface imaging being used very frequently, very commonly, but not transesophageal imaging.
Speaker: So it's been very interesting for me to see kind of how that these tools are being adapted, used and deployed within different specialties.
Speaker: and how they're evolving at different rates and different specialties.
Speaker: So now in anesthesiology, it's like all the hype is point of care ultrasound and surface imaging.
Speaker: And now we're seeing more in emergency medicine and in critical care, a transition to, well, what about transesophageal echo and how could we use that in our space?
Speaker: So how would you recommend people who are already out in practice, who did not get training in TE during fellowship, how do they even get started?
Speaker: Yeah, you know, I think that that is a very common and a very good question.
Speaker: I think first there is a component of getting familiarity with transesophageal echocardiography, and some of that can be done by doing workshops or taking classes like Philippe Turan's resuscitative TEE course that he runs across the country or some of these other courses that are offered by different societies, et cetera.
Speaker: I also think that it's important to kind of collaborate with other colleagues who do do trans esophageal imaging just to get a better understanding of like what educational offerings are even provided to them or to their trainees, or if they can help kind of, if you could join them even, like you could go and join maybe to see how trans esophageal imaging is done
Speaker: when cardiologists are doing it, for example, for, you know, maybe they're doing it to assess whether there's a thrombus prior to doing a cardioversion or in the operating room.
Speaker: So some of that is just familiarity with the procedure itself.
Speaker: And then the other becomes kind of, you know, decreasing your own internal barriers to
Speaker: for placing transesophageal probes once you have kind of some of that exposure and in patients who really would need it, for example, such as cardiac arrest patients who are actively being resuscitated.
Speaker: So you have to start somewhere and that includes getting a little bit of background information, getting some training and then picking up the probe and actually
Speaker: using it, particularly in patients where the benefits would far outweigh the risks.
Speaker: In regards to kind of
Speaker: certification processes, the National Board of Echocardiography has a critical care ECHO board certification that is offered and they have pathways for physicians in practice who are outside of training.
Speaker: If you're able to take the exam and submit your log for your surface imaging as part of that pathway,
Speaker: Once you basically get approved by the board, all you would have to do to get certified in transesophageal echo for the intensivist critical care echocardiography would be to submit a separate log of 50 exams that were performed by the board.
Speaker: you in critically ill patients.
Speaker: So there's no extra test.
Speaker: There's no extra step.
Speaker: That's the only step is to perform the exams, have them proctored and sent to the board.
Speaker: So that's a good pathway that's just actually opened up in this last year or two.
Speaker: Excellent.
Speaker: And I think that from what I understand, the literature has shown studies that with high-fidelity simulation, you probably need a lot less than 50 to be proficient in obtaining images at least.
Speaker: Is that correct?
Speaker: Oh, absolutely.
Speaker: Yeah, absolutely.
Speaker: Simulation plays a big role in this, and the simulators just get better and better.
Speaker: So, you know, when we hold, for example, our workshops for resuscitative TEE here,
Speaker: at the University of Washington with our emergency medicine colleagues.
Speaker: That's what we're using to get that baseline fundamental knowledge is just a high fidelity simulator.
Speaker: Excellent.
Speaker: So let's dive into the clinical topic that we wanted to discuss, which is the use of TE in cardiac arrest and peri-arrest or shock resuscitation.
Speaker: And maybe we can start, Sarah, with just, you mentioned fewer windows, and obviously a lot of our listeners who are doing transthoracic echocardiography or point-of-care ultrasound are familiar with some of the windows that we use in the transthoracic.
Speaker: What are the main windows that we utilize in TE and the ICU in these situations?
Speaker: Yeah, I mean, really, you know, the sky is the limit, but it's typically four windows.
Speaker: And the windows initially are the mid-esophageal four-chamber views, which would be equivalent to an apical four-chamber view for a transthoracic echo.
Speaker: The next would be a mid-esophageal long-access view, and that's very similar to either a
Speaker: apical three chamber or a parasternal long access view for surface imaging.
Speaker: The next would be a bicavel view, which would give you visualization of the SVC, the left atria, the right atria, and the IVC.
Speaker: And that view predominantly, I think, is helpful in our patient population because there have been studies that have been validated for volume responsiveness and evaluating SVC.
Speaker: basically diameter changes over the respiratory cycle for patients who are on mechanical ventilation.
Speaker: So that can be a very helpful view for that and also a helpful view for putting in lines.
Speaker: You know, during the resuscitation, you can see the wires going in through the SVC to confirm that you're in a good position for the lines that you're placing.
Speaker: And then the last would be the transgastric short access view.
Speaker: So you would push the probe into the stomach to get a short access view of the heart, the LV and the RV, just like a parasternal short access view at the level of the mid-papillaries.
Speaker: Perfect.
Speaker: And in terms of, we talked a little bit about this, but when we're doing TEs and cardiac arrest or shock, can you talk a little bit about on the safety concerns that people might have?
Speaker: Yeah, I mean, I think one thing that is really important is, you know, you would want to control the airway.
Speaker: You know, I think there is a real risk for, you know, losing the airway and you would want to make sure that the patient was, you know, intubated and the airway was controlled.
Speaker: If the patient has arrested and chest compressions are ongoing, you know,
Speaker: already the percentage of recovery for those patients is quite low, as you know.
Speaker: And this, like we had talked about with my emergency medicine colleague, you know, this often reduces the anxiety related to unknown contraindications, because there are contraindications for putting in a TEE probe.
Speaker: And if you don't understand what they are, you know, because we don't have background information on the patient, that can cause them anxiety.
Speaker: But when patients are arresting, you know, it's
Speaker: it's either get the information try to help them or just leave them in a state of you know demise basically um some of those absolute contraindications for the listeners who might be interested in hearing what they are as you know for te would be like a previous esophagectomy or an esophageal gastrectomy um the present of esophageal strictures for example
Speaker: or some sort of tracheoesophageal fistula or esophageal trauma.
Speaker: Those are typically kind of the main absolute contraindications, but there are a host of relative contraindications, as you can imagine, that you kind of have to weigh the risk versus the benefits of.
Speaker: So those are kind of two major safety issues that I think of today.
Speaker: The other thing that has been talked about, and I think this kind of, we can chat about this a little bit more later, is there have been some issues
Speaker: concerns about like, could there be thermal injury to the esophagus, particularly if the imaging is allowed to continue to run or in the setting of defibrillation.
Speaker: These days, most of the machines have an auto heat sensor.
Speaker: So if the imaging is looping, looping continuously, and you have been busy and have forgotten to freeze it, once the probe hits about 38 degrees, it'll automatically freeze the imaging and then
Speaker: Proceed with an auto cool of the probe.
Speaker: So that I think portion of it has become less of a safety concern.
Speaker: The safety concern in regards to esophageal, maybe burn injury or injury in the setting of defibrillation is kind of more theoretical, I would say, than actually proven.
Speaker: There was recently, I believe it was just maybe two years ago in 2023, a study that was done by a group of emergency medicine physicians looking at this in swine models because, you know, we don't have any data in humans.
Speaker: And in the swine model, they didn't see an increased risk of esophageal injury in the setting of defibrillation.
Speaker: And I will say, like in the operating room, we defibrillate people all the time.
Speaker: with TE probes in the mid-esophageal position.
Speaker: And we haven't, you know, anecdotally seen any increased risk of esophageal burn injury or injury in those settings.
Speaker: So I just don't think we have enough information there, but those would be kind of some of the main safety concerns.
Speaker: Perfect.
Speaker: So let's walk me through this.
Speaker: You are in the ICU and they call code blue.
Speaker: What happens?
Speaker: How,
Speaker: Tell me how do you react and how do you get that TEM running during this code?
Speaker: Well, you know, of course, we would deploy ACLS, the ACLS algorithm as usual.
Speaker: And part of that, you know, in the intensive care unit in particular means that if the patient's not intubated, that we would also intubate the patient and secure the airway.
Speaker: And for our codes, typically, you know, we have large teams that respond and someone is usually coming with an ultrasound probe.
Speaker: So,
Speaker: You know, I would grab the ultrasound probe after the airway was secured while chest compressions were ongoing and attach the TEE probe to it and then basically, you know, put lube on the TEE probe and a bite block.
Speaker: I would definitely put a bite block on the probe so that I could put in the patient and then place the probe.
Speaker: And kind of the beauty of it is at the head of the bed after the airway is secure, you're not really in anybody's way.
Speaker: And these machines are becoming smaller and smaller.
Speaker: And so you can kind of keep them up close to the head of the bed so they're not impeding on everybody else's practice and care of the patient.
Speaker: And then that way, you know, we get real time feedback on
Speaker: how chest compressions are happening.
Speaker: And I usually would start with the mid esophageal four chamber view because I think it's an immediate view.
Speaker: It's at zero degrees.
Speaker: It gives you a sense of RV, LV function.
Speaker: And also you can clearly see around the heart in case there's a big pericardial effusion.
Speaker: And you can see if the ventricles are actually being compressed or not.
Speaker: And then from there, I would typically omniplane to like between 120 to 140 or 160 degrees and get the mid-esophageal long access view.
Speaker: And that would give me a sense of the hand positioning of chest compressions were really appropriate because what we don't want is for the aortic valve or the LVOT or the aortic root to be getting compressed.
Speaker: during chest compressions you know that seems counterintuitive we want to be pushing blood out of the heart um through the lvot into the aorta not compressing it so
Speaker: That is kind of how I think TE could help with the quality of CPR.
Speaker: And then you would do all of the things that you would normally do while care is being provided.
Speaker: You'd have an opportunity to look at some of those other views and assess, you know, what's happening?
Speaker: Why did this patient arrest?
Speaker: Is there an effusion we can drain?
Speaker: Are they really hypovolemic?
Speaker: And what?
Speaker: We should be resuscitating with fluids.
Speaker: Is the RV failing?
Speaker: Is there a giant clot in transit?
Speaker: Do we need to change the way that we're supporting the heart from pressers and fluids to inotropes and inhaled pulmonary dilators, vasodilators?
Speaker: So I think that that is kind of the way that I think about deploying it in the setting of an arrest.
Speaker: And I think that one of the aspects of this that I want to go into more detail is kind of like the different roles that TEE can play in a cardiac arrest.
Speaker: And you mentioned obviously some of them, but...
Speaker: The other aspect of this is just from a practical kind of operational standpoint, you're probably not gonna run around the hospital with a T to codes on the floor, but both in emergency departments, ICUs or ORs, if you have the right setup, you can probably get that image very quickly once the patient's intubated, right?
Speaker: And that's probably where I think the money is going to be for now.
Speaker: So this is going to be very, I think, at least initially, very useful for ICU codes, right, patients who code in the ICU.
Speaker: Now, you mentioned that with transthoracic, one of the big problems of using this in codes is that a lot of times if either the people acquiring the images are not as expert
Speaker: Or if it's done outside of a protocol, it ends up delaying or interrupting chest compressions significantly.
Speaker: And I can see how with a sunk cost fallacy, right?
Speaker: Somebody's trying and trying to get an image and nobody's doing chest compressions.
Speaker: And before you know it, like four minutes went by, right?
Speaker: And obviously that's a big deal.
Speaker: So with TE, you did mention that once it's in, there's no interruption of chest compressions.
Speaker: People can keep doing what they're doing.
Speaker: They can shock.
Speaker: They can compress.
Speaker: All you have to do is stop for rhythm checks, but you're not really interrupting the CPR.
Speaker: Now, could you talk a little bit more about the quality of CPR?
Speaker: Because like you said, we've been putting our hands on the same place for the last 50 years.
Speaker: But since we started putting TEs, we have found that maybe that's not the best place for every patient.
Speaker: Yeah, exactly.
Speaker: I mean, I think that that is what has been so shocking to me is, you know, there is just, and I don't know why it was shocking, actually, because we know that no two individuals are the same, right?
Speaker: So why would the same hand position work for everybody?
Speaker: And now that I think about it and I've thought about it more and more, it's like, gosh, wow, that makes a lot of sense.
Speaker: Right.
Speaker: And so what we have been able to see is that, you know, people even maybe with your hands or with the Lucas devices that sometimes are being used to free people's hands, you have to adjust the positioning so you get ventricular compression because oftentimes in kind of that upper chest position.
Speaker: You know, mid leftward position that we've been putting our hands, we're compressing, you know, the aorta or the LVOT.
Speaker: And that is very counterproductive.
Speaker: So that has been a huge benefit of doing real time trans esophageal testing.
Speaker: imaging is just to get a better sense of are we in the right place.
Speaker: And what we do know is when we do adjust our hands or the devices and go to the place where we're getting ventricular compression, the end tidal CO2 tracings improve and the numbers improve and the return of spontaneous circulation percentages have improved.
Speaker: So that's a really big deal.
Speaker: I mean, that by itself is a huge deal, in my opinion.
Speaker: Well, and I think especially, right, when more and more guidelines keep reemphasizing that at the end of the day, the only thing that really makes a difference probably is whether CPR is of high quality and whether the patient has something reversible.
Speaker: Everything else is kind of like, doesn't really matter, right?
Speaker: I mean, sometimes we focus on things that are not that important.
Speaker: Now, you did mention...
Speaker: you would do that with a mid-esophageal longitudinal axis view?
Speaker: Is that what you look at?
Speaker: Yeah, you would look at the mid-esophageal long axis view.
Speaker: And in that view, you're able to see kind of the left atrium on top, the mitral valve in the middle of the screen, the LV on the bottom, and then from the LV you can see.
Speaker: You can see the LVOT, the aortic valve in long access and the ascending aorta typically, as well as some of the right ventricles.
Speaker: So that view gives you a lot of information about whether you're, you know, allowing for blood to really exit the heart and where your contractions are occurring.
Speaker: And what you want to see, obviously, is compression of the bulk of the ventricle and not the valve or the ascending aorta or the LVOT, right?
Speaker: Exactly, exactly correct.
Speaker: Perfect.
Speaker: So I think that's an important aspect that is quite unique of TEE compared to transthoracic.
Speaker: And really, I mean, if you think about it, the lack of delays and the ability to improve the quality of CPR is two pluses, right?
Speaker: I mean, they're that really speak in favor of TEE.
Speaker: Could you talk about the diagnostic role of TEE in cardiac arrest with just maybe some examples of things that you've seen in your practice or the literature mentions?
Speaker: Oh, gosh.
Speaker: I mean, I will say it has, I have examples of this almost daily, and that is not an exaggeration.
Speaker: So, for example, I have this patient once who was in the intensive care unit post-cardiac surgery, maybe a couple days out, and
Speaker: who had had a bradycardic arrest after a heart transplant when the pacemaker basically stopped working and the temporary pacer and ended up kind of crashing on ECMO.
Speaker: And the following day, the flows on the circuit were starting to go down and her crit was kind of dropping just a little bit.
Speaker: And I went to go do a surface image on her, understandably a very challenging patient for that.
Speaker: And I just couldn't see the right heart.
Speaker: Like I tried as best as I could and I couldn't see it.
Speaker: And I thought, am I not seeing it because my image isn't good or I don't have a good window or am I not seeing it because it's compressed?
Speaker: So then I put down immediately to follow a trans esophageal probe and she had a giant kind of clot, you know, a fusion around her right heart that was compressing her RVs.
Speaker: which, as you know, in the cardiac surgery patient population, you know, you get these localized effusions that can cause tamponade.
Speaker: And that's what was happening with her.
Speaker: And it immediately changed and directed our care.
Speaker: And we were able to intervene to help her.
Speaker: And she ended up walking out of the hospital and, you know, sent me a letter, you know, a year later as she was singing for a concert for a concert.
Speaker: heart basically event that we had and that was just so impactful.
Speaker: I had a patient just recently in the ICU who had, you know, bilirubin was climbing and she had had, for example, an aortic valve, mitral valve surgery and she had this
Speaker: I did all this surface imaging and she had some views, but it was really hard to understand why, what was going on.
Speaker: She had this giant perivalvular leak that became immediately available and visible when we did just some basic views on it.
Speaker: transesophageal echo.
Speaker: So I think, you know, those are just some, you know, simple examples.
Speaker: I mean, I've had other patients who've come in who have had big abdominal surgeries, who've been obese, had had drains different places.
Speaker: It was hard to get imaging.
Speaker: They've decompensated and you put in the probe and realize they've had an acute pulmonary embolism and that's why they're, you know, on three vasopressors and you can't make any headway.
Speaker: So it's just,
Speaker: I don't know, Sergio, it's like one example.
Speaker: It's after the other.
Speaker: And I think that it's fair to say that transthoracic can also offer you diagnostic tools that can give you an idea of what's going on, right?
Speaker: So the difference here is because you're right behind the heart and there's no, like, you don't have to go through the whole issue of acquiring images from the surface with everything that's in between the surface and the heart, you can see certain things better.
Speaker: And you can see certain things that otherwise are very hard to see with transthoracic.
Speaker: And I think a point example would be localized and fluid collections that can cause compressions on like the RV or other elements of the heart that could be an explanation for what's going on.
Speaker: So clearly...
Speaker: the diagnostic value is there when you find it, right?
Speaker: I mean, sometimes you might not see anything and that's okay because having that information just helps you focus, okay, what can we do for this patient?
Speaker: And my next question is, could you talk a little bit about the prognostic role of TE in cardiac arrest?
Speaker: Yeah, I think that, you know, we know certain things when they occur in cardiac arrest and are not intervened upon quickly lead to poor outcomes.
Speaker: And one of those things is RV dysfunction.
Speaker: So if RV dysfunction is allowed to persist,
Speaker: in an arrest and not immediately or very quickly acted upon, the chances of recovering those patients is really terrible.
Speaker: So I think that there is a real role for us to be able to have better visualization and thereby act quickly when we do see
Speaker: an etiology of the arrest to improve prognosis in those patients.
Speaker: Also, like you had talked about, the quality of CPR we know improves prognosis in patients.
Speaker: And so if we're able to use TE to improve the quality of the CPR we're delivering, then that is a factor for
Speaker: And the other, you know, space that I really think about, and we've talked about this a little, is patients with pseudo-PEA.
Speaker: You know, if we can figure out what caused the arrest and it's not, you know, a true PEA, then oftentimes we can really recover the patients, but it depends on how quickly we can act.
Speaker: You know, I mean, if the patients are...
Speaker: in extremis for a longer period of time because we're kind of flying in the dark and they're getting more and more acidemic and etc it becomes much harder to recover patients so time is of the essence in cardiac arrest which is why I think that you know having very good images that can help you make a decision become very important in these patients
Speaker: And I think that the other part that I would mention, and maybe not so common in patients in the ICU because they might have A-lines, but like you mentioned with obese patients, sometimes you can't even find a pulse.
Speaker: Is there a pulse?
Speaker: There's not a pulse, right?
Speaker: And cardiac standstill also, I think, has a lot of prognostic value and can help us guide, I mean, the code in terms of what's going on.
Speaker: Exactly.
Speaker: Exactly.
Speaker: What about, you mentioned a little bit about this earlier, Sarah, the procedural guidance with TEs during a cardiac arrest.
Speaker: So you talked about lines, I mean, but it can also help you in other ways, I guess.
Speaker: Yeah, I mean, you know, if there is an effusion, for example, that it may help you understand what approach you might want to take to train a pericardial effusion.
Speaker: It may help you understand what kind of support might be needed.
Speaker: And then once you decide what support that is to help guide, for example, cannula placements for ECMO, for temporary left ventricular support, such as impellas,
Speaker: For even placement of pulmonary artery catheters, if that's deemed to be important, you can kind of troubleshoot with using transesophageal echocardiography to see the balloon basically crossing the tricuspid valve, the RV into the pulmonary artery.
Speaker: So I think there are a lot of opportunities to use TE for procedural guidance in critically ill patients.
Speaker: In terms of, as we close, I mean, or kind of summarize the cardiac arrest and the use of T in cardiac arrest, could you share with us maybe some pearls and pitfalls that we should avoid in terms of using T during cardiac arrest?
Speaker: Yeah, I mean, I think one thing we talked about is control the airway and make sure the airway is controlled.
Speaker: That is a high priority and continue chest compressions.
Speaker: That is extremely high priority and probably the highest priority.
Speaker: I would just say that these probes are very expensive.
Speaker: So put in bite blocks because you never know as patients wake up and oftentimes during arrests are not given a lot of sedatives initially.
Speaker: They could wake up and bite down on the probes and damage the probes, damage their teeth.
Speaker: So put in bite blocks.
Speaker: I think that's really important.
Speaker: The other thing I would say is don't leave probes in place, especially locked and unsupervised.
Speaker: If you are done with them, then remove them if you no longer need them, because the longer they stay in place, of course, they put pressure on the mucosal tissue and the esophagus and
Speaker: can cause esophageal injury and fistulas.
Speaker: If they're placed in a locked position and someone doesn't know and they're in like a flex position, for example, and someone comes and moves a probe, they could really kind of tear the esophagus, which would be really bad.
Speaker: So never leave them in a locked position.
Speaker: And then we talked about, you know, pausing the imaging when you don't need it so that the probes don't overheat.
Speaker: I would say some things that people don't think about is just the practicality components of things.
Speaker: So there should be some sort of system in place on how the probes are cleaned, how they are stored, how they are tracked.
Speaker: You don't want to ever risk basically, you know, putting a probe that's not cleaned and processed appropriately from one patient to another.
Speaker: You don't want to lose your probes if you can't track them.
Speaker: So there has to be some system in place.
Speaker: That would be a kind of a system-based PERL that I'll offer.
Speaker: And then being able to save and store images to optimize communication with the other care providers and also to allow for you and your colleagues to have a quality assessment and a quality improvement process are really important.
Speaker: So I would say those are just some of my biggest pearls or takeaways as you're thinking about starting down this pathway.
Speaker: Perfect.
Speaker: In terms of situations of shock resuscitation or peri-arrest when the patient is crashing but still a code is not being called, is there anything in particular that you would call out?
Speaker: And IVCT has been frequently utilized in post-cardiac surgery for these situations, but anything in particular you would call out for these patients?
Speaker: You know, I would just say, you know, some of this is about using your clinical acumen and deciding when it's important to deploy a tool that's within your repertoire.
Speaker: There are certain patients where using TE sooner rather than later probably is going to give you more information, and those patients are typically in the patients who are post-cardiac surgery.
Speaker: just because of the fact that the heart has been intervened upon and typically they have, you know, chest bandages and mediastinal drains and all sorts of different things.
Speaker: I would probably have a lower threshold in that patient population.
Speaker: And then in medical patients who are complex and could have multiple etiologies of shock, I think that that's another group of another patient population that may be really beneficial, you know, as you're trying to kind of rule things out and having good imaging might be important.
Speaker: The reason I mentioned this is because some of these, in these patients, oftentimes,
Speaker: Your quick decision-making leads to consultation of other colleagues who can intervene.
Speaker: So quickly being able to get the cardiac surgeon to the bedside, taking the patient to the cath lab, for example, or, you know, getting any sort of support devices that might be needed.
Speaker: That oftentimes takes time, and the quicker you can make that determination, the better ultimately it is for the patient's
Speaker: Perfect.
Speaker: As we move forward and start closing the topic, what are some of the key questions that, in your opinion, Sarah, are still kind of need to be further studied or defined in the use of resuscitation T in the ICU?
Speaker: Well, I would say outcomes research.
Speaker: I mean, that's probably a big area for most things.
Speaker: But outcomes research for TEE and resuscitation is really quite lacking.
Speaker: And I would say particularly as it associates or pertains to harms associated with TEE.
Speaker: And then ultimately like recovery, time to recovery and ultimate outcomes.
Speaker: We talked a little bit about, you know, what has been done in this space and what hasn't been.
Speaker: And as it relates to potentially esophageal entry and defibrillation.
Speaker: But I think that is kind of our biggest space.
Speaker: And then the other would be really some more understanding of what is the best educational kind of,
Speaker: algorithm or protocol for getting people up to speed in TE for resuscitation.
Speaker: And I think this is a space that is actively being explored and there is some data here, but it's not super robust.
Speaker: So those would be some of the big areas of interest.
Speaker: I would be very interested to see some data come out in these areas.
Speaker: What are you most excited about in the near future with TE in the ICU?
Speaker: I mean, honestly, just like anything, I think it's reducing barriers to help physicians, clinicians, practice providers help their patients, you know, help patients recover and grow a skill set that can be really useful for informed decision making.
Speaker: That's what makes me honestly the most excited and brings me back to work every day and challenges me personally and professionally.
Speaker: It sounds kind of simple, but I guess...
Speaker: It's at the base of everything that I do.
Speaker: So you won't stop until every intensivist has a TE probe in his hands, right?
Speaker: Well, I definitely will be happy when I see my colleagues more comfortable using it.
Speaker: So what would you tell our listeners who are not using TE and cardiac arrest at this point?
Speaker: You know, I would say...
Speaker: There is some real utility to doing this, and I've seen it with my own eyes, and there is some data to support that.
Speaker: I would say that it definitely seems scary because it's invasive, but with proper training and a systems-based practice, you can pick it up.
Speaker: It is a skill cell that is within your competency to know how to use, and it can help impact patient care.
Speaker: This is a wonderful discussion on the use of TE in cardiac arrest.
Speaker: As we close the podcast, we usually like to ask our guests a couple of questions that are unrelated to the clinical topic.
Speaker: Would that be okay, Sarah?
Speaker: Yeah, absolutely.
Speaker: Awesome.
Speaker: So my first question relates to books.
Speaker: Is there a book or books that have influenced you significantly or a book that you have often gifted to other people?
Speaker: Oh, wow.
Speaker: Yeah, that is a hard question because I love to read.
Speaker: But yeah, somehow an easy question to answer.
Speaker: I don't know if you've heard of the book.
Speaker: I'm sure you have because you also love to read, Sergio.
Speaker: It's called The Prophet by Khalil Gibran.
Speaker: Have you heard of it?
Speaker: I have heard about it and I have read it.
Speaker: Yes, absolutely.
Speaker: It is probably the book I love the most and have gifted the most to my friends and anyone who will listen.
Speaker: For those listening to the podcast who haven't read it, it is a book that was written in the 1920s by this Lebanese-American poet and writer named Khalil Gibran.
Speaker: And...
Speaker: is probably one of his best known works.
Speaker: It's been like translated, I don't know, over maybe a hundred different languages and it might be one of the best selling books of all time.
Speaker: But it's a story basically about a prophet or a young man who lives in the city outside of wherever his hometown is.
Speaker: And he's getting ready to go back to his hometown and on the way,
Speaker: out the people of the town kind of stop him and ask him to talk to them about different topics of life and the topics end up really touching on the human condition um so you know they'll say tell us about marriage or tell us about giving tell us about joy uh and he talks about it and there's this one and this is how big of a dork i am that i have literally memorized this but there is this one um
Speaker: There is this one section on love where someone asks him, please speak to us of love.
Speaker: And he looks up, you know, in this basically poem, and he says, when love beckons you, follow him, though his ways are hard and steep.
Speaker: And when his wings enfold you, yield to him, though the sword hidden among his pinions may wound you.
Speaker: And when he speaks to you, believe in him.
Speaker: Though his voice may shatter your dreams as the north wind lays waste to the garden, for even as love crowns you, so shall he crucify you.
Speaker: And even as he is for your growth, he is for your pruning.
Speaker: Even as he ascends to your heights and caresses your tenderest branches that quiver in the sun, so shall he descend to your roots and shake them in the clinging to the earth.
Speaker: And that is just...
Speaker: you know, just one example of the many different beautiful poems that are in this book.
Speaker: And I think obviously I have to read it again.
Speaker: I mean, I haven't read it in a long time.
Speaker: But what I think is two things come to mind immediately.
Speaker: One is that my grandfather always would tell me that old books are always good because only the good ones make it to old.
Speaker: The fact that it was written many, many years ago, I think it's testament to its lasting power.
Speaker: But also what you find when you read different books that are, let's say, from other eras and from different cultures, when they talk about the human condition and you find these common threads, it makes you really wonder.
Speaker: There has to be something that's really powerful and true when different people, different eras, different places of the world kind of talk about
Speaker: things in a similar way, right?
Speaker: Without necessarily maybe learning from each other.
Speaker: So definitely, I think this is a wonderful book and we'll definitely put a link in the show notes.
Speaker: Awesome.
Speaker: Thanks for sharing that.
Speaker: And I'm really impressed that you have memorized that, I have to say.
Speaker: Yeah, it's like the only one of all of them, I think, because it touched me so deeply.
Speaker: But yeah, it is.
Speaker: Yeah, it's a great, great book.
Speaker: I really recommend it to anyone.
Speaker: You know, it's beautiful.
Speaker: Awesome.
Speaker: So my second question relates to something you changed your mind about in the last couple of years.
Speaker: So could you share with us something that you changed your way of thinking about in the last couple of years?
Speaker: You know, that's a really timely question because, you know, I'm sure like many of the people on this podcast, you know, we intensivists, we like to do things in a big way.
Speaker: You know, it's like you don't do it unless you can just do it.
Speaker: giant and have a big impact.
Speaker: And my, unfortunately, my father-in-law passed away a little over a year ago.
Speaker: And as he was dying and still very coherent, he's just such a beautiful man.
Speaker: He said to us, he was 90 and he said to us, you know, in my life, the thing, the greatest thing that I've learned is that the world can be a better place.
Speaker: And he said, it doesn't have to be a better place, but it can be a better place.
Speaker: And the way that it is a better place is by each of us bringing the best part of ourselves forward to help make it a better place.
Speaker: And in that moment, I think I really understood what he was trying to say.
Speaker: And that was that every day that you are bringing the best bit of yourself forward, even if it seems like a little thing, even if it doesn't seem to be a giant project or a giant, you know, action, you are impacting the world in a positive way to make it a better place.
Speaker: And that has really changed my perspective.
Speaker: And I think the approach that I'm taking kind of on a day-to-day basis to,
Speaker: the things that I do to my life, to my interactions with people.
Speaker: I don't know if that makes any sense, but that was really impactful for me.
Speaker: No, absolutely.
Speaker: And I think definitely, first of all, sorry for your loss, but it sounds like at 90 and with that wisdom, a wonderful life lived, right?
Speaker: Which should be celebrated.
Speaker: And I do agree.
Speaker: It's about moving the needle, right?
Speaker: I mean, you can't solve every problem, but if you can make things a little bit better today and keep moving forward,
Speaker: I think it does make a difference.
Speaker: And like you said, that's how we contribute to making the world a better place.
Speaker: So thanks for sharing that.
Speaker: It's beautiful.
Speaker: And as we close, Sarah, is there anything you want to make sure that every listener thinks about?
Speaker: It can be a thought, a quote, or just a closing thought on what we talked about.
Speaker: Yeah, I think, you know, to be honest, I think that it's just to share that, you know,
Speaker: What we do, what you do, is challenging.
Speaker: And we practice in this space where evidence-based practice changes from year to year.
Speaker: Like one year they say, oh, it's good to keep the glucose within this range.
Speaker: And then the next year they say, oh, you should liberalize it.
Speaker: So it just changes from moment to moment.
Speaker: And we've gotten a lot of criticism in the past about
Speaker: as it relates to evidence to support the use of critical care ultrasound in the care of patients.
Speaker: And I will just say that, you know, Dr. Diaz Gomez and I just co-chaired this, you know, new guideline update for critical care ultrasound through the Society of Critical Care Medicine.
Speaker: And what we were able to find was that there is some evidence available to support the use of critical care ultrasound in the care of patients.
Speaker: Is it high quality evidence?
Speaker: No, of course it's not, because it's really hard to study this.
Speaker: in these patients.
Speaker: So I guess what I'm just trying to say is that, you know, you can do this.
Speaker: It is within your capability to do.
Speaker: And sometimes you see the evidence in front of your eyes and that pushes you to pick up a skill or to grow in your practice.
Speaker: And that's okay and totally, you know, acceptable in my opinion.
Speaker: So
Speaker: Just to say that, you know, I just am so honored to be part of this community.
Speaker: And I know the struggles that we all face, but I also know the beauty and the care of which we take our patients and whatever you can do to do that better.
Speaker: It's something that, you know, you should explore, in my opinion.
Speaker: So I think we can stop here.
Speaker: Perfect place to stop.
Speaker: I was muted, sorry.
Speaker: But what I was saying is I just want to thank you, Sarah, for sharing your expertise, your enthusiasm, and most of all, giving us your time to really talk about this very important topic.
Speaker: And I hope to have you back in the podcast to talk about this another topic soon.
Speaker: Thank you so much.
Speaker: Thanks for your time and for this lovely invitation.
Speaker: It's been a real pleasure for me.
Speaker: Excellent.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
