Newsletter

Dr. Stevenson's Response to President's Message

I am pleased to have been offered the opportunity to comment on the President's Message: "Anesthesiology and Pediatric TEE". I welcome your effort to draw broader attention to these important issues. I address these comments to all of us who are involved in intraoperative TEE in pediatrics, with the hope of improving communication, cooperation and understanding. I seek a continuing dialogue leading to improved performance of intraoperative TEE.

Dr. Thys has made comments regarding the relative weight of science and of description in my article (1). First, it should be clear that the circumstances surrounding the events reported in my article precluded certain aspects of scientific design and analysis. Indeed, since publication of the article I have learned that some of the untrained individuals assigned to perform intraoperative TEE studies sought assistance from on-call cardiologists who also did not meet training guidelines for TEE. Even together, their performance commonly failed. Second, it is obvious that a multi-center trial was out of the question. Further, I did not believe that an IRB would be willing to confirm support for the ethics of even a single center study of this type. Thus, the traditional procedures and safeguards that we look for in prospective clinical research were subverted by administrative decision. Even with these limitations, however, the message from our experience is that individuals performing TEE must be trained.

Some have asked why I prepared this paper at all. I presented the paper because of my conclusion that we had experienced an unfortunate situation that adversely affected patient care. I felt responsible to present the facts of the occurrence with the hope that the situation would not be repeated in other centers. In this way, my report is not unlike other reports of unintended adverse outcomes from drug or treatment regimens.

From my previous experience with intraoperative TEE, it was my opinion that performance of TEE by physicians insufficiently trained in TEE would be unwise, and that asking individuals to perform two complex services simultaneously would compromise both. But how to test my opinion and what standard of reference to use? I chose the ASE/SOPE Guidelines for Transesophageal Echocardiography in Children (2) as an appropriate published reference. A number of organizations publish such guidelines and recommendations, but I was unable to find any references that actually tested the impact of such guidelines on patient outcome. Thus, my paper served a second purpose, to test the utility of a guideline document. I set very low thresholds for outcome criteria, and avoided any assessment of the sonographic quality of the examinations, specifically seeking not to sensationalize the result. The results and conclusions speak for themselves; patient care suffered. With that fact clearly established, the experience now gives us an opportunity to improve our intraoperative TEE services, whether provided by anesthesiologists or cardiologists.

The important message is that the individual performing intraoperative TEE must be "sufficiently trained". In my experience, and from the experience I have gathered from other centers, it matters little whether one's primary background is cardiology or anesthesia. Indeed, anesthesiologists have been major participants in the evolution of intraoperative TEE since the very beginning. Unfortunately, some have read Dr. Fyfe's editorial (3) as being unkind or disrespectful of our anesthesia colleagues. In reading the editorial, my interpretation is that it is an appropriate and passionate indictment of those pressures and decisions that can affect medical practice today. Further, it reinforces the necessity of proper preparation and training in this particular aspect of patient care. And finally, it asserts that the individual performing TEE must not have additional important responsibilities that could divert time and attention from TEE at critical moments.

We are a group of physicians sharing a common belief that intraoperative TEE is useful. We may utilize it differently from center to center, but overall, we have each identified applications which we believe can lead to improvements in patient care. We need to move beyond the emotions of how unfortunate decisions can be made, and beyond aspects of editorial interpretation. In doing so, we come to the most important item that we can do something about: training.

What is "sufficient training" for TEE? Clearly the relatively simple elements of the Guidelines were enough to separate adequate from inadequate TEE performance as described in my paper. Dr. Thys questions whether these are the best guidelines for use today. As they are the only published pediatric guidelines, they must be the best, but obviously the point is: could we do better. It has been 7 years since those ASE/SOPE Guidelines were published. The application of intraoperative echocardiography for congenital heart disease has evolved considerably during this interval. While all would agree that a basic modicum of ultrasound knowledge, experience and skill is required for the optimal performance of intraoperative TEE, perhaps it is time to re-evaluate and update our recommendations regarding the specifics of TEE training. To this end, the SCA/ASE Task Force may provide a useful forum addressing these issues. Since many aspects of intraoperative TEE for congenital heart disease differ from those for acquired heart disease, it would be critical that the SCA/ASE Task Force include the authors of the original pediatric guidelines document. It is entirely possible that workload responsibilities and work distribution will not be found to be the same for all operative procedures. Indeed, since the applications of intraoperative TEE differ in significant respects for congenital and acquired heart disease, we may need to formulate more than one set of guidelines.

I have two comments regarding the FAA analogy that appears in the President's Message. First, we who are involved in TEE should be the ones to determine practice standards and recommendations, not an outside group. I would also comment that I am not a pilot. I would not attempt to operate an aircraft without proper training. Nevertheless, we have all observed some TEE novices flying by the seat of their pants in the operating room. This part of the analogy is important, because the absence of a crash is not proof of skill in flying. In the operating room, suboptimal outcomes can occur without a crash. Indeed, many of the problems that were not detected by those inexperienced in TEE were not large enough to cause a "crash" at the time of operation, and they went undetected.

Dr. Thys suggests that we undertake a scientific study to examine "workload and work distribution as pediatric cardiac patients are separated from bypass ". At the recent ASE meeting, a paper from our intraoperative team was presented that begins to address some of these important issues (4). It may take the kind of study that Dr. Thys suggests in order to reach consensus, and define practice guidelines for TEE.

In the meantime, however, I suggest we be prepared to provide undivided attention to TEE. This means that in the operating room, especially for congenital heart disease, we should have a trained individual dedicated to TEE. We all have experienced that when a case proceeds smoothly, the anesthesiologist has ample time to perform TEE. But when things are not proceeding smoothly, we have also seen that even the most skilled of anesthesiologists are necessarily devoted to critical aspects of patient management precluding an adequate TEE assessment of problems, or an assessment of response to the specific interventions implemented. This is not a limitation inherent to anesthesiologists, but just a simple fact that one's attention, TEE skills, and physical actions cannot be effectively utilized in two complex arenas simultaneously.

In preparation for a presentation on TEE at the recent American Society of Echocardiography meeting, I surveyed 70 North American centers performing surgery for congenital heart disease. One of the questions asked was "who performs the actual (intraoperative) TEE examination?" No center responded that an anesthesiologist alone performed the TEE examination. One center responded that the anesthesiologist and sonographer performed the TEE together. All other centers reported that the TEE was done by a cardiologist, about half in association with a sonographer. So, by current consensus, it appears that the vast majority of centers currently recognize the practical limitations of a single individual performing TEE while conducting anesthetic care. Until such time as data from the study Dr. Thys proposed may alter practice, I suggest we continue to follow the majority practice of TEE today.

We have work to do to further the appropriate use of intraoperative TEE in pediatrics. I welcome Dr. Thys' call for better sharing of information between our Societies. The American Society of Echocardiography has many members who are anesthesiologists. With the participation of anesthesiologists in ASE, we have gained increasing communication and cooperation. Larger echocardiographer participation in the Society of Cardiovascular Anesthesiologists should have the same effect. As one of the co-authors of the pediatric Guidelines, I would be happy to review them in promoting the continuing evolution of TEE. We bring different skills and talents to the operating room where we work together toward the goal of excellence in patient care. Let's continue that legacy of cooperation and respect as we move forward.

References

1. Stevenson JG. Adherence to Physician Training Guidelines for Pediatric Transesophageal Echocardiography affects the outcome of patients undergoing repair of congenital cardiac defect. J Am Soc Echocardiogr 1999;12:165-72

2. Fyfe DA, Ritter SB, Snider AR et al. Guidelines for transesophageal echocardiography in children. J Am Soc Echocardiogr 1992;5:40-44

3. Fyfe DA. Transesophageal echocardiography guidelines: return to bypass or bypass the guidelines? J Am Soc Echocardiogr 1999; 12:343-44

4. Ramamoorthy C, Lynn A, Williams GD, et al. Utility of transesophageal echocardiography, as assessed by anesthesiolgists, during surgery for congenital heart disease. J Am Soc Echocardiogr 1999;12:420

J. Geoffrey Stevenson, M.D., F.A.C.C.

Professor of Pediatrics, Cardiology

University of Washington School of Medicine

Director, Cardiac Ultrasound

Children's Hospital

Seattle, WA