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INTRODUCTION

Transoesophageal echocardiography (TOE) is a complex monitoring and diagnostic modality requiring specific cognitive and technical skills. Indications for TOE in the perioperative period have been clearly stated by the Task Force of the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists (Task Force 1996). Information derived from a diagnostic TOE examination is made available to other medical practitioners and may be used to guide or assist their management decisions.

1.   THE TRANSOESOPHAGEAL ECHOCARDIOGRAPHY EXAMINATION

A diagnostic TOE examination comprises:

1.1   A full diagnostic study including spectral and colour Doppler analysis (Shanewise, Cheung et al. 1999), unless this is not achievable in a specific clinical situation.

1.2   Pre and post bypass studies in those cases involving cardiopulmonary bypass.

1.3   Video-taping, or equivalent, of key elements of the investigation and archival storage of all study recordings.

1.4   A formal written report with patient identification and including the name of the person conducting the examination, with one copy archived and one copy in the patient records.

1.5   A mechanism for peer review of study recordings.

2.   TRAINING

Appropriate training for the use of transoesophageal echocardiography in the peri-operative setting is essential. (Cahalan and Foster 1995; Savage, Licina et al. 1995) Training guidelines have been published by other organisations (Intercollegiate Consensus Statement; Cardiac Society of Australia and New Zealand; Cahalan, Abel et al. 2002)

2.1   Training should be under the direct supervision of experienced practitioners, who shall have met standards equivalent to those outlined in this document. Such training should include both performance and interpretation of TOE examinations with no concurrent clinical responsibilities for the trainee.

2.2   The period of training should be at least the equivalent of 50 days full-time (based on Intercollegiate Consensus Statement) over a minimum period of ten weeks to a maximum period of two years. An initial two week period of full-time training is strongly recommended.

2.3   During the period of training, the trainee should perform:

2.3.1   Initially, a number of supervised TOE procedures to achieve and demonstrate competence to perform and report complete diagnostic TOE examinations. This would usually be expected to require 50 complete TOE examinations.

2.3.2   At least 50 unsupervised TOE examinations that have been reviewed with a supervisor.

2.3.3   At least 100 additional supervised reviews and reports of pre-recorded TOE examinations.

The trainee must be exposed to a wide range of cardiovascular pathology and at least 50% of TOE examinations should be undertaken in the operating theatre.

2.4   Prior to completion of TOE training, practitioners are encouraged to use TOE in a clinical environment to further develop their skills. In such circumstances, diagnostic information should only be used with caution to guide anaesthetic management. Information gained from the TOE examination should only be used to guide or assist other medical practitioners in their management decisions in consultation with an experienced practitioner.

2.5   Attendance and participation in post-graduate courses (e.g. Postgraduate Diploma in Perioperative and Critical Care Echocardiography, University of Melbourne), workshops and continuing medical education programs dedicated to peri-operative TOE is strongly recommended during the training period and thereafter.

3.   DOCUMENTATION OF TRAINING

3.1   A log book (or equivalent database) must be maintained during the training period to record:

3.1.1   the number and case-mix of TOE examinations performed and/or reviewed.

3.1.2   training courses attended.

3.2   The logbook should be available for review by a supervisor both during and on completion of the training period.

4.   SAFETY

4.1   TOE is a semi-invasive procedure and appropriate skill and judgement is required when placing and manipulating the probe to reduce the risk of injury to the patient or damage to the probe.

4.2   If intraoperative TOE is performed by the patient’s anaesthetist, an experienced assistant may be required to assist in monitoring patient parameters. This is particularly the case when there is the combination of a very unstable clinical situation and particularly complex TOE interpretation issues.

4.3   TOE must always be used in an environment where there are adequate facilities and staff to decontaminate and clean the TOE probe after use. There must be a documented protocol for cleaning the probe and a log to record compliance.

5.   SUPERVISORS

Where trainees must be supervised and their reports reviewed by an “experienced practitioner”, then such a practitioner must have documented training equivalent to that described in 2.1 to 2.5 or in 5.1 to 5.3. Supervisors must comply with Maintenance of Standards as specified in 6.

5.1   Medical practitioners who can demonstrate by log book or other verifiable means, 100 completed diagnostic TOE studies and have obtained the Postgraduate Diploma in Perioperative and Critical Care Echocardiography from the University of Melbourne, or passed the Perioperative Transesophageal Echocardiography Examination (PTEeXAM) which is administered by the National Board of Echocardiography in the USA.

5.2   Practitioners who have satisfied the requirements of the Australian Society of Ultrasound in Medicine (Intercollegiate Consensus Statement 1995) and are regular practitioners of TOE in a tertiary medical institution.

5.3   Practitioners who have satisfied the requirements of the Cardiac Society of Australia and New Zealand for training in echocardiography.

6.   MAINTENANCE OF STANDARDS

After appropriate training in transoesophageal echocardiography has been undertaken, practitioners must maintain appropriate standards of proficiency in TOE examinations. This should include:

6.1   Performance of at least 30 TOE examinations every year.

6.2   Reviews of at least 50 TOE study recordings with qualified colleagues every year.

6.3   Attendance and participation in post-graduate courses, workshops and continuing medical education programs on peri-operative TOE and related subjects.

REFERENCES

Task Force on Transesophageal Echocardiography. (1996) Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists. Anesthesiology 84(4): 986-1006

Shanewise, J.S., Cheung, A.T. et al. (1999) “ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography.” Anesth Analg 89(4): 870-84.

Cahalan, M.K. and Foster, E. (1995). “Training in transesophageal echocardiography: in the lab or on the job?” Anesth Analg 81(2): 217-8

Savage, R.M., Licina, M.G. et al. (1995). “Educational program for intraoperative transesophageal echocardiography.” Anesth Analg 81(2): 399-403.

Intercollegiate Consensus Statement (1995). Guidelines for Medical Practitioners Performing and Interpreting Diagnostic Ultrasound. Australian Society of Ultrasound Medicine Newsletter , October 1995 Vol 18:1.

Cardiac Society of Australia and New Zealand Standards For Training In Adult Echocardiography
Website -http://www.csanz.edu.au/guidelines/training/echo_stan.cfm

Cahalan MK, Abel M, Goldman M et al. (2002). “American Society Of Echocardiography and Society of Cardiovascular Anesthesiologists Task Force Guidelines for Training in Perioperative Echocardiography.” Anesth Analg 94:1384-8.

(Website - http://www.scahq.org/sca3/tee_guidelines.pdf)

COLLEGE PROFESSIONAL DOCUMENTS

College Professional Documents are progressively being coded as follows:

TE Training and Educational

EX Examinations

PS Professional Standards

T Technical

POLICY – defined as ‘a course of action adopted and pursued by the College’. These are matters coming within the authority and control of the College.

RECOMMENDATIONS – defined as ‘advisable courses of action’.

GUIDELINES – defined as ‘a document offering advice’. These may be clinical (in which case they will eventually be evidence-based), or non-clinical.

STATEMENTS – defined as ‘a communication setting out information’.

This document has been prepared having regard to general circumstances, and it is the responsibility of the practitioner to have express regard to the particular circumstances of each case, and the application of this document in each case.

Professional documents are reviewed from time to time, and it is the responsibility of the practitioner to ensure that the practitioner has obtained the current version. Professional documents have been prepared having regard to the information available at the time of their preparation, and the practitioner should therefore have regard to any information, research or material which may have been published or become available subsequently.

Whilst the College endeavours to ensure that professional documents are as current as possible at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Promulgated: 2002

Date of current document: Feb 2004

© This document is copyright and cannot be reproduced in whole or in part without prior permission.

College Website: http://www.anzca.edu.au/