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1、Locally Agreed Guidelines May Reduce Inappropriate Preoperative Echocardiography Requests,Dr Sheila Carey Anaesthetic SpRNorthern Deanery,Background:Preoperative Echocardiography,Assessment of perioperative cardiac risk is part of anaesthetic preoperative assessment.Echocardiography can give useful
2、information on cardiac function but has its limitations.,Background:Sunderland Experience,Disquiet from cardiology regarding quality and appropriateness of echo requests.Uncertainty about indications for pre-operative echo amongst PAAC staff and junior surgical medical staff.,Aims,Audit all preopera
3、tive echocardiogram requestsProduce local guidelinesSurvey local consultant opinion regarding pre operative echoLiterature reviewEvaluate impact of guidelines,Preoperative Echo Survey:Who needs investigating?,New murmur with other indicators of ASNew murmur with no suggestive features of ASStable an
4、ginaDecompensated heart failureKnown AS.No change in symptoms,no recent echo(1 year),Published Literature/Guidance,ACC/AHA GuidelineRecommendations for pre-op non-invasive evaluation LV FunctionPatients with current or poorly controlled HF*(Class I)Patients with prior HF/patients with dyspnoea unkno
5、wn origin(Class II)Valvular heart diseaseIf a murmur is present,the clinician will need to decide whether or not it represents significant valvular diseaseAS poses the greatest risk,Published Literature/Guidance,NCEPOD1994/5Patient with ESM in association with LVH or myocardial ischaemia should be r
6、eferred for assessment2001Patients can be asymptomatic despite mod severe AS and hence an asymptomatic cardiac murmur should be investigated preoperatively by echocardiographyNCEPOD recognises the spiralling increase in workload this causes but echocardiography services should be accorded an appropr
7、iate priority with regards funding,Published Literature/Guidance,Appropriateness Criteria for TTE and TOE(ACCF/ASE/ACEP et al)Symptoms due to suspected cardiac aetiology(not previously investigated)(9)Initial investigation of murmur where there is reasonable suspicion of valvular or structural disea
8、se(9)Re-evaluation of a patient with known valvular heart disease with a change in clinical status(9)Routine(yearly)evaluation of an asymptomatic patient with severe stenosis(7),Published Literature/Guidance,Pandit(2004)Maximising the benefit from pre-operative cardiac evaluationThe uninvestigated m
9、urmurNCEPOD guidelines extremely cautiousImplementation would increase demand greatly on echo servicesLocal guidelines should be jointly developed,Review of Echocardiogram requests,Preoperative requests collected over a 6 week period.Reviewed by Consultant Cardiologist to determine appropriateness.I
10、nappropriate requests patient note review.Indications compared against new guidelines,Results,Twenty eight requests for preoperative echocardiography7/28(25%)deemed as acceptable by Cardiology21(75%)unacceptable requests14 murmurs/added sounds4 Left ventricular Function3 nature of surgery,Analysis o
11、f Unacceptable Requests,16 Unacceptable requests from Trauma&Orthopaedic Department12 sets of notes reviewed9 requests could have been prevented(75%)using guidelines,Conclusions 1,No consensus amongst senior medical staff regarding who requires investigationPersonal preference probably dictates choi
12、ce except when clear cut suspicion of AS Advice given to other staff,(e.g.trainees,PAAC nurses)likely to be inconsistentGuidelines may improved this,Sunderland echocardiogram request,Conclusions 2,A significant proportion preoperative echocardiogram requests are unacceptableRetrospective application
13、 of guidelines suggests inappropriate requests could be reducedPotential for a rise in number of requests if patients selected more appropriately,Limitations,Cardiology review subjectiveRetrospective analysisProspective Audit needed to clarify the effect of introducing guidelines,Recommendations,Investigation should only be considered if management will be affectedInformation given on request form has to be relevant and detailedLocal guidelines can help direct appropriate use of resources,
