TOE in Theatre: The Probe Earns Its Keep copertina

TOE in Theatre: The Probe Earns Its Keep

TOE in Theatre: The Probe Earns Its Keep

Ascolta gratuitamente

Vedi i dettagli del titolo

Offerte di stagione | 0,99 €/mese per i primi 3 mesi

A seguire 9,99 €/mese – si applicano condizioni. Puoi disdire mensilmente.
A proposito di questo titolo
 Last episode we put a probe on the chest. This one goes down the oesophagus — and it starts somewhere uncomfortable. Inserting a transoesophageal probe is something we do to a patient that can cause them significant harm. Maybe once a year, sometimes more, a patient comes to harm because an anaesthetist put a probe down. We do a great many of these, so it is not unreasonable to think we sometimes cause damage and never find out. But sometimes the injury is severe: an oesophageal tear, upper gastrointestinal bleeding. Severe harm runs at roughly one in two thousand, from a UK audit by the Association of Cardiothoracic Anaesthetists, with female sex, steroid use and a low body mass index as risk factors — all observational, so hold it loosely. And then the argument that follows from it. Contraindications are genuinely hard to find, and Mike's position has changed over time: transoesophageal echo should be mandatory for essentially all cardiac surgery unless there is a good reason not to. Not because every operation demands it, but because of what turns up — valvular problems and dissections in patients listed for bypass grafts with supposedly normal hearts, things that would never have been found without scanning them on the table. From there, the practical half. Three ways to get an ejection fraction, in ascending order of rigour: the eyeball, which in experienced hands correlates well and is what you'll actually use in a crashing patient; fractional area change from the transgastric short axis; and Simpson's biplane, the most rigorous and the most dependent on an endocardial border you can genuinely see. Garbage in, garbage out. Then the right ventricle, and an argument worth having: there are many accepted ways to assess it, and the very existence of so many tells you that none is good enough alone. Watch TAPSE being measured in theatre and ask honestly whether that is a precise, scientific number — particularly off-axis on a transoesophageal probe. Most of the time what you are doing is judging performance by eye and following the trend: how it looked before, how it looks now, what you did in between, and whether it worked. Plus the levers when the right ventricle is struggling — rate and rhythm, preload, afterload, contractility and coronary perfusion, and what comes after them. Systolic anterior motion gets done properly this time, and the key idea is that echo lets you predict it rather than just diagnose it: a long anterior mitral leaflet, a small hypertrophied ventricle with a narrow outflow tract, and a short coaptation-to-septum distance. Then the management, which runs almost exactly opposite to instinct. Then the probe as a theatre instrument. Siting a balloon pump tip just distal to the subclavian — and what goes wrong if it sits too high or too low. The Protek Duo, and why its tip must sit beyond the pulmonary valve. And the rule worth carrying out of the whole topic: any patient on mechanical support with haemodynamic instability does not have to do very much to earn a scan. The section Mike calls most underrated is the one where you help the surgeon and the perfusionist. The venous drainage cannula that has slipped into a hepatic vein — presenting as low flows and poor drainage that everyone assumes is volume — and the non-standard view that finds it. Confirming the retrograde cardioplegia cannula in the coronary sinus, which protects the heart for the entire operation. And watching the wires: the femoral venous wire in peripheral bypass, and the balloon pump wire in the descending aorta, with a live commentary nobody else in the room can give. We finish with transplantation — what is and isn't useful to scan, why a heart that has just been ischaemic cannot be judged like a normal one, and the three questions all of this monitoring exists to answer before you take that patient out to the unit. Chapters (00:00) Cold open — the probe can hurt people(01:00) One in two thousand, and the risk factors(01:40) Contraindications, and how few there are(02:20) Who should get one — and why the answer changed(03:20) Accreditation for cardiac anaesthetists(03:50) Ejection fraction: eyeball, FAC and Simpson's biplane(05:00) The right ventricle, and why so many methods is a warning(06:20) The levers when the right ventricle is failing(07:00) Predicting systolic anterior motion before it happens(08:00) Treating it when it happens(08:40) Siting a balloon pump(09:20) The Protek Duo(10:10) Instability on support earns a scan(11:00) Which pipes you can actually see(11:50) Helping the surgeon: the cannula in the hepatic vein(12:50) Confirming retrograde cardioplegia in the coronary sinus(13:20) Watching the wires(13:50) Transplantation(15:00) Wrap-up Key takeaways Putting a probe down can seriously harm a patient: severe harm is around 1 in 2000, with female sex, steroids and low BMI as observational risk factorsContraindications are few — oesophageal pathology or swallowing difficulty...
adbl_web_anon_alc_button_suppression_t1
Ancora nessuna recensione