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Department of Anesthesiology, Wayne State University, Detroit, MI, rkbaumgarten{at}comcast.net
To the Editor:
Our specialty’s fixation with ultrasound-guided nerve blocks may be distracting us from the real ultrasound revolution in medicine. Physicians in emergency medicine and critical care are using ultrasound extensively. Bedside ultrasound diagnosis should be incorporated into clinical anesthesia.
Ultrasound (U/S) allows real-time detection of cardiac tamponade, pneumothorax, severe hypovolemia, and pleural effusion (1,2). Rapid diagnosis of these conditions in the operating room or recovery could be life-saving. Cardiac arrest due to ventricular fibrillation often responds to prompt electrical shock. Pulseless electrical activity (PEA) has a much poorer prognosis. Early U/S evaluation can detect potentially reversible causes of PEA in real time (3). The presence or absence of cardiac activity on U/S is highly predictive of the success of CPR (4). Fortunately, cardiac arrest is rare in the OR and recovery. When it does occur, prompt use of portable U/S may salvage an otherwise disastrous situation.
There is mounting evidence in the critical care literature that U/S can improve the safety and efficacy of internal jugular cannulation. Despite these evidence-based recommendations, anesthesiologists are reluctant to use U/S for line placement (5).
U/S also has mundane uses, which while not life-saving, could improve efficiency and patient satisfaction. Many emergency departments now use U/S for patients with difficult venous access (6). Anesthesiology has been slow to adopt this strategy, even though difficult IV access is a frequent cause of patient complaints. U/S can also speed the placement of radial artery catheters (7).
Evaluation of bladder volume is another potential use of U/S. Many ambulatory facilities require spontaneous urination before discharge. Patients can spend hours in recovery waiting to urinate. It is often difficult to determine whether delayed urination is due to impaired micturation from residual anesthesia or not enough urine in the bladder to trigger urination. Dedicated bladder volume instruments exist (e.g., BladderScan®), but they are quite expensive (
$15,000). Newer bedside U/S machines can be used to assess bladder volume. The savings in recovery costs alone might justify the acquisition of portable U/S.
Intravenous fluid therapy (30 mL/kg) is effective for the prevention of PONV, especially in patients at high-risk for this problem (8,9). However, the possibility of bladder distension is of concern. Ready availability of U/S to measure bladder volume could make fluid loading a useful alternative to expensive pharmacologic antiemetics.
Many question the purchase of a $70,000 U/S machine for nerve blocks that have been done with a $600 nerve stimulator. A broader justification is needed. While the most common source of disaster in anesthesia is airway compromise, for other causes of precipitous deterioration in our patients, bedside U/S may be invaluable for rapid diagnosis and effective treatment. By helping us discharge patients more rapidly, U/S could produce significant cost savings. Emphasizing the myriad benefits of U/S may convince hospitals to provide high-quality, portable U/S for anesthesia departments. At the same time, we in anesthesia must master new U/S skills so that our specialty can join the ultrasound revolution.
REFERENCES
This article has been cited by other articles:
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  C. Barker, P. Jefferson, and D. R. Ball Portable Ultrasound to Diagnose True Radial Artery Aneurysm Anesth. Analg., September 1, 2007; 105(3): 890 - 891. [Full Text] [PDF]
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T. K. Harrison, T. Manser, S. K. Howard, and D. M. Gaba Cognitive Aids in a Simulated Anesthetic Crisis Anesth. Analg., May 1, 2007; 104(5): 1293 - 1293. [Full Text] [PDF]
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