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• W1970204080 abstract "Among the many opportunities available to the cardiac sonographer, the operating room is possibly the most elusive and challenging environment of all. This setting currently accounts for only a small percentage of employment opportunities for sonographers, and their appropriate role in the operating room has been slow to evolve. The invasive nature of obtaining transesophageal echocardiography (TEE) clinical data and the somewhat restrictive current guidelines for TEE training and reporting are the primary reasons for the small numbers of registered sonographers working within the perioperative environment. While many sonographers see the operating room as an opportunity to advance their roles in the diagnostic process, the current boundaries are clear. ASE and the Society of Cardiovascular Anesthesiologists (SCA) recently published a joint document entitled “ASE/SCA Recommendations and Guidelines for Continuous Quality Improvement in Perioperative Echocardiography.”1Mathew J.P. Glas K. Troianos C.A. Sears-Rogan P. Savage R. Shanewise J. et al.ASE/SCA recommendations and guidelines for continuous quality improvement in perioperative echocardiography.Anesth Analg. 2006; 103: 1416-1425Crossref PubMed Scopus (38) Google Scholar This document supports the position paper, “Guidelines for Cardiac Sonographer Education: Recommendations of the American Society of Echocardiography Sonographer Training and Education Committee,”2Ehler D. Carney D.K. Dempsey A.L. Rigling R Kraft C. Witt S.A. et al.Guidelines for Cardiac Sonographer Education: Recommendations of the American Society of Echocardiography Sonographer Training and Education Committee.J Am Soc Echocardiogr. 2001; 14: 77-84Abstract Full Text PDF PubMed Scopus (77) Google Scholar stating that “the role of the sonographer in the performance TEE is limited to maximizing image quality by the manipulation of the controls on the ultrasonography system.” Outside of the perioperative environment, the boundaries for sonographers' responsibilities may be relaxing. “Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography: Recommendations of the American Society of Echocardiography Council on Cardiac Sonography”3Waggoner A.D. Ehler D. Adams D. Moos S. Rosenbloom J. Gresser C. et al.Guidelines for the cardiac sonographer in the performance of contrast echocardiography: Recommendations of the American Society of Echocardiography Council on Cardiac Sonography.J Am Soc Echocardiogr. 2001; 14: 417-420Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar and recent sonographers' communications within this journal highlight the developing role of the sonographer in contrast administration. After recognizing a clinical need, the ASE highly recommends that cardiac sonographers take the appropriate steps to become trained in the administration of contrast agents. These communications identified an area where guidelines for patient care could be usefully and safely expanded. An initiative to define educational requirements and competencies that would allow this newly expanded area of contrast cardiac sonography to develop has been productive. There may also be room for expanding the role of the sonographer within the demanding and dynamic domain of perioperative echocardiography. The growing clinical importance of TEE in the operating room brings with it changes and new opportunities. Recognizing the need to be proactive in embracing these opportunities, the Massachusetts General Hospital created an intraoperative sonographer position. The Division of Cardiothoracic Anesthesia and the Noninvasive Echocardiographic Laboratory considered utilizing the unique skills of a credentialed cardiac sonographer within the operating room for performing intraoperative echocardiographic studies. This interest emerged around the need to reevaluate the role of the anesthesiologist or cardiologist as the clinician solely responsible for intraoperative TEE. In 1999, the Cardiac Anesthesia Group of the Department of Anesthesia and Critical Care at Massachusetts General created my position as technical director of intraoperative echocardiography education. Many might consider this a pioneering decision. I have now held this position as a sonographer in the operating room for over 10 years, during which my responsibilities have continuously evolved. I have a major role in the education and training of cardiac anesthesiologists, fellows, and residents, as well as cardiac surgical residents in perioperative echocardiography. I assist the cardiac anesthesiologists in performing a complete systematic exam preoperatively and postoperatively to ensure that accurate and timely data are available for the surgeon and that quality control is maintained. In addition to hands-on intraoperative teaching and didactic conferences, I am responsible for ongoing maintenance, updating equipment (Live 3-D, etc), and operation of the ultrasound equipment. I adjust the ambient lighting in the intraoperative setting to closely resemble reading room conditions for image quality and interpretation. I process billing for probe insertions and clinical TEE performed by the anesthesiologists and maintain statistics on the exams performed by the department for management and credentialing purposes. I ensure timely reading of the studies by the cardiologists. Cardiac anesthesia staff members, fellows, and residents participate in this process to further their education and training. I also help the fellows and residents prepare echocardiographic presentations for various conferences. I have assembled a comprehensive cardiac anesthesia primer for anesthesia fellow TEE education and guidelines. In the midst of all of these responsibilities, my key intraoperative role is to work alongside the anesthesiologist to facilitate his or her primary goal of patient care while at the same time aiding them in providing a quality echocardiographic study for the surgeon. For more than a decade, the continuing growth of intraoperative TEE has revealed a new and unique set of challenges. Conduct, interpretation, and clinical application of echocardiography in the perioperative environment are complex and often difficult, requiring focus, appropriate knowledge, technical skills, and complete familiarity with clinically important surgical considerations. As in any field, advances are driven by recognition of needs and opportunities. Stevenson's4Stevenson J.G. Adherence to physician training guidelines for pediatric transesophageal echocardiography affects the outcome of patients undergoing repair of congenital cardiac defects.J Am Soc Echocardiogr. 1999; 12: 165-172Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar “Adherence to Physician Training Guidelines for Pediatric Transesophageal Echocardiography Affects the Outcome of Patients Undergoing Repair of Congenital Cardiac Defects” reports that “patient outcome is beneficially affected when intraoperative TEE is performed by physicians who meet published guidelines and whose sole intraoperative responsibility is the performance of TEE.” In a supporting editorial, “Transesophageal Echocardiography Guidelines: Return to Bypass or to Bypass the Guidelines?” Fyfe5Fyfe D. Transesophageal echocardiography guidelines: return to bypass or to bypass the guidelines?.J Am Soc Echocardiogr. 1999; 12: 343-344Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar concludes that “there is a conflicting responsibility of serving as both the intraoperative anesthesiologist and echocardiographer in complex pediatric cardiac cases.” Furthermore, Fyfe suggests the following ideas. The expert assessment provided by a fully trained pediatric echocardiographer immeasurably helps to refine the preoperative diagnosis. As a consultant, the pediatric echocardiographer aids in this diagnosis by the addition of optimal imaging quality provided by TEE, which is useful for the anticipation of potential problems and recognition of subtle residual defects that otherwise may be overlooked. The successful care of the cardiac surgical patient requires a team of experts with subspecialty expertise who acknowledge their limitations, yet create synergy with their skills. These ideas may be extrapolated to complex adult cardiac cases as well. Up to this point, essentially all technical aspects of performing and interpreting a comprehensive intraoperative TEE examination have been the responsibility of a physician. We are currently confronted with a cardiovascular surgical population of patients with increasing perioperative morbidity, who require more complex procedures. With appropriate training, careful restructuring of the guidelines, and appropriate supervision, perhaps one of the opportunities afforded to the cardiac sonographer in the future could address the answer to the question, Who will be left holding the probe?" @default.
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• W1970204080 title "The Cardiac Sonographer in the Operating Room: Who's Left Holding the Probe?" @default.
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