Focused cardiac and lung ultrasonography: Implications and applicability in the perioperative period

Abstract

Focused ultrasonography in anesthesia (FUSA) can be a procedural and diagnostic tool, as well as potentially a tool for monitoring, and can facilitate the perioperative management of surgical patients. Its utilization is proposed within the anesthesiologist and/or intensivist scope of practice. However, there are significant barriers to more generalized use, but evidence continues to evolve that might one day make this practice a standard of care in the perioperative period. Currently, the most widely used applications of FUSA include the guidance and characterization of perioperative shock (acute cor pulmonale, left ventricular dysfunction, cardiac tamponade, and hypovolemia) and acute respiratory failure (pneumothorax, acute pulmonary edema, large pleural effusion, major atelectasis, and consolidation). Increased diagnostic accuracy of all of these clinical conditions makes FUSA valuable in the perioperative period. Furthermore, FUSA can be applied to other anesthesiology fields, such as airway management and evaluation of gastric content in surgical emergencies.

Full text

Perioperative focused cardiac and lung ultrasonography
Adres s for correspondenc e: José L. Díaz-Gómez, MD
Dep ar tme nts of Anesthe sio logy,
Critica l Care, and Neurosurgery
Mayo Clinic
4500 San Pablo R oad
Jack sonville, FL 322 24 USA
E-mai l: Diazgomez.jos e@ma yo.e du
Romanian Journal of Anaesthesia and Intensive Care 2016 Vol 23 No 1, 41-54
REVIEW ARTICLE
Focused cardiac and lung ultrasonography: implications and
applicability in the perioperative period
José L. Díaz-Gómez1,2,3, Gabriele Via5, Harish Ramakrishna4
1 Department of Critical Care Medicine, Mayo Clinic FL, USA
2 Department of Anesthesiology, Mayo Clinic FL, USA
3 Department of Neurologic Surgery, Mayo Clinic FL, USA
4 Department of Anesthesiology, Mayo Clinic AZ, USA
5 Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
Abstract
Focused ultrasonography in anesthesia (FUSA) can be a procedural and diagnostic tool, as well as
potentially a tool for monitoring, and can facilitate the perioperative management of surgical patients. Its
utilization is proposed within the anesthesiologist and/or intensivist scope of practice. However, there are
significant barriers to more generalized use, but evidence continues to evolve that might one day make this
practice a standard of care in the perioperative period.
Currently, the most widely used applications of FUSA include the guidance and characterization of
perioperative shock (acute cor pulmonale, left ventricular dysfunction, cardiac tamponade, and hypovolemia)
and acute respiratory failure (pneumothorax, acute pulmonary edema, large pleural effusion, major atelectasis,
and consolidation). Increased diagnostic accuracy of all of these clinical conditions makes FUSA valuable
in the perioperative period. Furthermore, FUSA can be applied to other anesthesiology fields, such as
airway management and evaluation of gastric content in surgical emergencies.
Keywords: focused cardiac ultrasound, lung ultrasound, shock, hypoxemia
Received: 2 February 2016 / Accepted: 1 March 2016 Rom J Anaesth Int Care 2016; 23: 41-54
Introduction
Ultrasonography in the anesthesiology and critical
care environments provides noninvasive, rapid, and
accurate diagnostic information for patients with
potentially life-threatening conditions. In contrast to for-
mal comprehensive echocardiography via cardiology
services, focused cardiac ultrasound evalua tions
provide quickly obtained goal-oriented information [1],
which is better suited for the dynamic state of the
surgical patient in the perioperative period [2, 3].
Focused cardiac ultrasound –
sonoanatomy
Focused cardiac ultrasound exclusively uses the
simplest modalities of Echocardiography: 2D and M-
Mode. The preliminary step is being cognizant of the
The combined application of both focused cardiac
and lung ultrasound is very useful in the initial
assessment of surgical patients who present with shock
and/or acute respiratory failure in the perioperative
period. This new ultrasonography-driven approach has
significantly evolved over the past few years. Initially,
most indications for FUSA were related to central
venous vascula r access and regional anesthesia.
However, FUSA is currently touted as the most useful
point-of-care imaging modality that can enhance
diagnostic accuracy. This review will facilitate an
understanding of the utilization of ultrasound-guided
focused cardiac and lung ultrasound in the perioperative
setting.
DOI: http://dx.doi.org/10.21454/rjaic.7518.231.lus

Díaz-Gómez et al.42
standard position of the probe on the chest that is needed
to acquire adequate images of the heart and great
vessels. In emergency conditions, the subcostal view
should be obtained first in order to avoid any delay in
the commencement of chest compressions if cardiac
arrest occurs (Figure 1). To facilitate orientation, the
indicator on the transducer corresponds to the marker
on the side of the ultrasound sector on the monitor (by
convention, the marker is displayed in the top right of
the ultrasound sector). This is the standard position of
the marker adopted by most echocardiography labo-
ratories.
The cardiac probe has a small footprint to create
the acoustic windows through the intercostal space.
The application of firm pressure along with gel is ne-
cessary to optimize the ultrasound conduction between
the skin and transducer. The probe should be held like
a pen for all views, except the subcostal view where it
should instead be gripped from the top (Figure 1E).
Fig. 1. Subcostal view. A. Orientation of the probe indicator; B. Direction of the ultrasound beam on the heart; C. Identification of
heart chambers on subcostal view; D. Echocardiographic appearance of the subcostal view; E. Overhand grip of the ultrasound probe
– only used for the subcostal view (by permission of the Mayo Foundation for Medical Education and Research; all rights reserved)
Basic scanning movements with the
transducer
The following transducer movements are funda-
mental in order to procure all transthoracic echocardio-
graphy views. Hence, it is crucial to acknowledge them
so the focused cardiac ultrasound examination is
accurately performed in a timely fashion.
Sliding: displacement of the probe between higher
or lower intercostal spaces. This is an important initial
movement while procuring the parasternal long-axis
view, but is generally applicable to all views.
Rotation: the clockwise or counterclockwise move-
ment of the probe while maintaining the same axis of
penetration of the ultrasound beam. This probe
movement is applicable to all views.
• Clockwise: from the parasternal long axis to the
short axis view (from 10 o’clock to 2 o’clock)
• Counterclockwise: from the subcostal 4-chamber
view to the IVC view (from 3 o’clock to 12
o’clock); from the apical 4-chamber to the 2-
chamber view (from 3 o’clock to 12 o’clock)
Rocking: Incline the probe in the plane of the
indicator. In the apical view, for example, tilting of the
probe to your right (patient’s left side) will facilitate
the visualization of the right ventricle free wall.
Tilting: Incline the probe in a plane perpendicular
to the one of the indicator. For example, in the para-
sternal short axis views, this movement is crucial in
the identification of different planes from the base of
the heart (aortic valve and right ventricular outflow
tract, then the mitral valve, and finally the mid-papillary
view) (Figure 2).
Important caveats to obtaining a good view
1. After obtaining a “reasonably good” view, only
perform slow movements with the probe to optimize.
2. Perform one movement at any given time to
understand how the image changes according to your
manipulations (i.e., do not combine rotation and tilting
or sliding and rocking, etc.).
Optimizing echocardiography images
The following probe manipulations are helpful for
optimizing transthoracic echocardiography images once
a reasonably good view has been obtained.

Perioperative focused cardiac and lung ultrasonography 43
Fig. 2. Parasternal short-axis view. A. Orientation of the probe
indicator; B. Direction of the ultrasound beam on the heart; C.-H.
Identification of the hear t cham bers and ech ocardiographic
appearance on parasternal – short-axis view; C.-D. Aortic valve
level; E.-F. Mitral valve level; G-H. Mid-papillary level. This
transition of views is achieved while the sonographer makes a
tilting (“fanning”) movement of the probe. The aortic level view is
obtained with superior “fanning” of the probe and mitral level and
mid papillary view with inferior direction “fanning” of the probe
(by permission of the Mayo Foundation for Medical Education and
Research; all rights reserved)
Parasternal Long-Axis:
• The four criteria are important to assure a good
parasternal long-axis view:
– Lack of visualization of the apex in the image obtained
– Visible aortic and mitral valves
– Horizontal orientation of the heart
– Recognition of the descending aorta
• If LV apex is visible, slide the transducer more
medially (closer to the sternum).
Parasternal Short-Axis (midpapillary) View:
• At times, the best view is obtained by sliding the
probe one intercostal space up or down. If this is not
successful, obtain the long-axis parasternal view again
and start rotation from the right to the left shoulder
very slowly.
• If LV is asymmetric, rotate the transducer either
clockwise or counterclockwise.
Apical:
• If the heart appears to be tilted to the right, slide
the probe more laterally and vice versa.
• If the atria chambers are not visible, use upward
rocking (anterior to posterior) movements.
• If you are unable to visualize the right ventricle,
attempt to tilt the transducer to the right.
Subcostal:
Flatten (lower) the angle between the transducer
and the skin as much as possible. A good point of
reference is the visualization of both atrioventricular
valves in the same plane.
Position of the patient and the operator and
probe orientation
Often the perioperative patient is lying in the supine
position. This is the most convenient position to obtain
the subcostal view. In contrast, the left lateral decubitus
position enables a closer position of the heart within
the chest wall and improves the image quality of the
apical and parasternal views. This can be more easily
attempted in the Post-anesthesia Care Unit (PACU)
or during the preanesthesia assessment.
To facilitate image interpretation, the cardiac
ultrasound views are obtained by cutting planes that
either intersect the major axis of the heart (long-axis
views characterized by including the image structures
of the base and apex of the heart) or that are perpen-
dicular to this axis (short-axis views).
The Focused Assessed Transthoracic Echocar-
diography (FATE) protocol is a focused cardiac
ultrasound protocol commonly applied in the periope-
rative period [4]. We utilize the FATE protocol for the
illustration of the echocardiography views. In the
sections below, a distinct, practical, ultrasound-driven
approach to shock and acute respiratory failure will
be described (Figure 3).
In Table 1, the techniques for obtaining the echo-
cardiographic views during focused cardiac ultrasound
are described.
Using M-mode to assess inferior vena cava (IVC)
diameter facilitates the calculation of the distensibility
index (patients receiving mechanical ventilator y
support) or collapsibility index (spontaneously
breathing patients) and starting from the initial subcostal
view, use a counter-clockwise rotation from 3 o’clock
to 12 o’clock (90°) (Figure 4).

Díaz-Gómez et al.
44
Table 1. Focused Cardiac Ultrasound – obtaining echocardiographic views
Loca t i o n o f tr an sd u ce r P r o b e o r ie n t at i o n
ma r ke r
Sect o r De p th
on m on i t o r
Help f u l t i p s
Subcostal 2 cm below xyphoid process or
slightly toward RUQ if chest tubes
in place
~ 2-3 o’clock 15-25 cm Hold the transducer from the top; apply
angulations between 10-40 degrees.
Supine position, bend knees (if able)
Subcostal –
Inferior
Vena Cava
From the previous view r otate the
transducer 90 degrees
counterclockwise
~ 12 o’clock 15-20 cm Keep junction of right atriu m and IVC in the
center of the screen. Need to appreciate the
IVC merging into right atrium
Apical Find the point of maximal impulse
if feasible. Otherwise from anterior
axillar line to nipple. Female
patients – under the breast crease
~ 3 o’clock 14-18 cm Probe must be angled (60 degrees) toward
right hemithorax. Assure good contact with the
rib. You are “sneaking” in between those two
ribs!
Parasternal –
long axis
3rd – 4th intercostal space ~ 11 o’clock
(Patient’s right shoulder)
12-20 cm
(24 cm if pleural/
pericardial effusion
are suspected)
Left lateral decubitus position if not able to
obtain a “good view” in supine position
Parasternal –
short axis
Rotate 90 degrees clockwise from
the parasternal-long axis view,
so ~ 2 o’clock
~ 2 o’clock
(Left shoulder)
12-16 cm With “ ti lt in g” mov em ent o f the pr ob e
Aortic valve level: the transducer face slightly
upward toward the patient’s right shoulder
Mitral valve level: the transducer is
perpendicular to chest wall
Papillary muscle level: the transducer faces
slightly downward toward the patent’s left
flank
Fig. 3. FATE protocol (by permission of the Mayo Foundation
for Medical Education and Research; all rights reserved)
(expressed as percentage)
A distensibility index of >18% predicts fluid res-
ponsiveness with a positive predictive value of 93%
and a negative predictive value of 92% [5].
Fig. 4. Subcostal – IVC view. Distensibility Index (Mechanical
Ventilation): M-Mode assessmen t of th e Inferior Vena Cava
Variation. The phase array marker should be oriented cephalad (12
o’clock). A gentle right to left “sweep” movement will facilitate
the recognition of the IVC to right atria junction. The IVC diameter
measurement should be taken 2 cm to 3 cm from the IVC to the
right atrial ju nction ( by permission of the Mayo Foundation for
Medical Education and Research; all rights reserved)
The apical 4-chamber view is similar to the subcostal
view (vertical versus horizontal orientation of the heart
on the screen). Thus, it is helpful to compare these
two echocardiographic views (Figure 5).

Perioperative focused cardiac and lung ultrasonography 45
Fig. 5. Apical view. A. Orientation of the probe indicator; B. Direction of the ultrasound beam on the
heart; C. Identification of heart chambers on apical view; D. Echocardiographic appearance of the apical
view (by permission of the Mayo Foundation for Medical Education and Research; all rights reserved)
Lung ultrasound – sonoanatomy
While a significant portion of critical care and
surgical anesthesia imaging is dedicated to transthoracic
echocardiography, ultrasonographic imaging of the lung
has demonstrable benefit in diagnosing patients with
acute respiratory failure with or without concomitant
arterial hypotension. For instance, the initial FATE
protocol included the examination of the pleura with
the intention of describing large pleural effusion that
can contribute or cause arterial hypotension in critically
ill patients [4]. A growing body of evidence has shown
excellent sensitivity and specificity in identifying
pneumothorax, pulmonary edema, COPD exacerbation,
and pneumonia in the critically ill patient population
[6]. Furthermore, the combination of focused cardiac
and lung ultrasound facilitates the characterization of
pulmonary edema (hydrostatic versus nonhydrostatic)
in critically ill patients [7].
This section summarizes an overview of lung
ultrasound in the perioperative period. First, we describe
the sonoanatomy of lung using the linear (high-fre-
quency) probe. Second, we present the clinical signifi-
cance of lung ultrasonography. Third, an ultrasound-
driven approach with patients with acute respiratory
failure in the perioperative period is presented.
Step 1: Technique and identification of normal and
abnormal signs/patterns in focused lung ultra-
sonography with the linear probe:
Technique: As described previously by Lichtenstein
[8], the anterior chest wall can be divided in four
quadrants while the patient is in the supine position.
The linear probe should be longitudinally applied
perpendicular to the wall for all quadrants. In the case
of an unclear image, rule out the presence of sub-
cutaneous emphysema or an overlying obstruction
(dressings, EKG pads, etc.) (Figure 6).
Lung ultrasound in the perioperative period
As with focused cardiac ultrasound, a significant
portion of lung ultrasonography relies on the recognition
of ultrasound “patterns” that are pathognomonic of
associated disease processes. Lung ultrasound requires
the integration of the segmental patterns (at each
scanning spot) together in an overall lung pattern [9].
A complete lung ultrasound examination requires linear
and phased array transducers. While direct visualization
of the pleural-lung interface, of pleural effusions, and
of completely de-aerated lung areas (consolidations)
is possible, the air-filled lung cannot be visualized. It is
in fact obscured by the high ultrasound reflectivity of
the air-tissue interface represented by the end of pre-

Díaz-Gómez et al.46
Fig. 6. Lung Ultrasound Technique. A. Two-dimensional imaging of normal lung and pleural sliding using a
linear probe. Maximal depth is 6 cm; B. Probe should be placed perpendicular to the chest wall with the probe
indicator facing cephalad. Gentle tilting improves the images due to increased reflection of pleural line
(by permission of the Mayo Foundation for Medical Education and Research; all rights reserved)
pleural tissues and the beginning of the aerated lung
tissue (at the level of the pleural layers) touching. To
overcome this limitation, the artefacts from this
phenomenon have been studied and have been distilled
into specific ultrasound patterns associated with specific
pathologies.
Initial assessment: patients with clinical suspicion
of pneumothorax or complete atelectasis – the
“Five Ls” Approach
The following LUS signs are based on the Interna-
tional Meeting on Lung Ultrasound Conference, which
standardized all of them with expert consensus [6].
The first step (lung/pleura sliding) should be per-
formed with the higher frequency linear probe (7.5-
12 MHz). This linear transducer provides improved
resolution of structures that are closer to the probe or
in the near field, most notably the pleura. As such,
examination for clinical suspicion of pneumothorax
lends itself to this technique.
1. First “L” – Lung Sliding: A sliding movement
between the visceral and parietal pleura is described
as the “lung sliding sign” [6]. It consists of the respi-
rophasic shimmering of the pleural line, the ultrasound
representation of the pleural layers touching (i.e., the
physical site of the tissue-air interface mentioned
above). It is a dynamic process demonstrated with two-
dimensional ultrasonography in real time. Detection of
this finding in the parasternal areas of the lung rules
out pneumothorax (in the site of scanning) with 100%
NPV. When the lung sliding is not detected, pneumo-
thorax is possible but needs a confirmatory sign obtained
by the extension of the exam to the lateral regions of
the chest (see “lung point” below). Other conditions
such as adhesions due to previous thoracic surgeries,
very low lung compliance, may otherwise mimic
absence of lung sliding and pneumothorax. Sono-
anatomy and Lung Sliding: The obtained sonographic
image includes: (1) subcutaneous tissue and intercostal
muscles (2) the ribs and (3) the pleural line (a
hyperechoic line) (Figure 6).
The representation of this lung sliding in M-mode
complements the evaluation including the static thoracic
wall (hence represented by straight lines), and the
dynamic pleural line movement generates dynamic
distal artifacts (represented as a granular pattern that
has been referred to as the “seashore sign” because
its appearance is similar to sand on a beach). The
absence of lung sliding in M-mode has been called the
“barcode sign” (Figure 7) [10, 11].
2. Second “L” – Lung Point: The lung point is a
useful sign for the confirmatory diagnosis of pneumo-
thorax. It can be found in real time (two-dimensional
ultrasound) or M-mode. It indicates the dynamic point
of transition (at inspiration) between normal sliding and
the absence of sliding (i.e., the point where the lung
again touches the chest wall, the boundary of a
pneumothorax air collection). This sign is considered
very specific (98%-100%) for pneumothorax (Figure
7) [12-14].
3. Third “L” – Lung Pulse: The lung pulse is a
useful sign for the diagnosis of absence of ventilation,
potentially leading to complete atelectasis; when the
lung area investigated is in this condition, it shows an
intermittent small motion synchronous with the
heartbeat, meaning that there is still air content in the
lung that is no longer in communication with the airway
(the non ventilated lung area becomes like a bag full
of air, receiving and transmitting the kicks of the
“beating neighbor”). The cardiac pulsation appearance
at the pleural line in M-mode and the absence of lung
sliding in real-time two-dimensional ultrasonography
characterizes the lung pulse sign. The sensitivity and
specificity of the lung pulse sign for complete atelectasis
are 70%-99% and 92%-100%, respectively (Figure
8) [15].

Perioperative focused cardiac and lung ultrasonography 47
Fig. 7. A. Normal lung and pleural sliding using a linear probe and M-mode; B. M-mode representation of the Lung point and
partial pneumoth orax (mix of granular-norma l with arrows and horizontal-pneumothorax patterns); C. Barcode sign,
pneumothorax. The linear probe marker should be oriented cephalad (12 o’clock). A slight tilting of the probe will facilitate the
recognition of higher reflectance and ultrasound appearance of the pleural-lung interface and sliding movement (by permission
of the Mayo Foundation for Medical Education and Research; all rights reserved)
Fig. 8. Two dimen sional and M-mode representation of Lung
pulse. Lung pulse is suggestive of major lung collapse. The linear
probe marker should be or iented ce phalad (1 2 o’ clock) (by
permission of the Mayo Foundation for Medica l Education and
Research; all rights reserved)
4. Fourth “L” – “A” Lines: Under normal con-
ditions, the ultrasound signal in the lung is completely
reflected by the tissue-air interface at the level of the
pleural line. This reflection generates reverberations
that project the pleural line beyond itself in the mid and
far field as horizontal artifacts that are parallel to the
pleural line and are multiplicative of the distance
between the skin and the pleural line. The “A” lines
constitute the basic artifact of normal lungs (Figure
9). It is important to acknowledge that in absence of
any pleural motion (either lung sliding or lung pulse [8,
16, 17]), “A” lines are also present in case of pneu-
mthorax.
5. Fifth “L” – “B” Lines: These lines describe
the change in the normal artifacts of the lung and are
determined by a change in density of the subpleural
lung tissue content (pathological involvement of the
lung interstitium or the alveolar airspaces, or thickening
of interlobular septa). This is either a consequence of
increased extravascular lung water or of decreased
air content. The “B” line is defined as a hyperechoic
laser-like signal that fans out from the pleural line that
moves with the pleural sliding and reaches the edge of
the screen, erasing the “A” lines. At least three lung
comets between two ribs in one longitudinal scan must
be identified to constitute a positive “B pattern”, the
hallmark of this change in peripheral lung density. One
of the most useful applications of lung ultrasonography
in the perioperative patient is the early detection of
acute interstitial pulmonary edema, especially in patients
who undergo surgical operations without any preope-
rative respiratory symptoms (Figure 10). Moreover,
other causes of the alveolar-interstitial syndrome that
can present “B” lines include pneumonia and pre-exist-
ing pulmonary fibrosis. Hence, the ultrasound visuali-
zation of interstitial pulmonary edema syndrome is not
specific for pulmonary edema but highly sensitive; its
Fig. 9. Representation of normal “A” lines with linear transducer.
These lines have horizontal orientation. The linear probe marker
should be oriented cephalad (12 o’clock) (by permission of the
Mayo Foundation for Medical Education and Research; all rights
reserved)

Díaz-Gómez et al.
48
applicability in previously asymptomatic patients in the
perioperative setting makes it a very valuable tool [18].
Fig. 10. Representation of abnormal “B” lines with phase array
transducer. The phase array probe marker should be oriented
cephalad (12 o’clock). These lines have vertical orientation and are
well defined and laser like. “B” lines arise from the pleural line,
erase “A” lines, and move with lung sliding. They also should
extend throughout the field shown on the image. In this case, there
are five “B” lines which are suggestive of pulmonary edema (by
permission of the Mayo Foundation for Medica l Education and
Research; all rights reserved)
The anesthesiologist can face the clinical scenario
of hypoxemic acute respiratory failure due to pul-
monary edema. Certainly, a combined focused cardiac
and lung ultrasound examination can increase the
diagnostic accuracy at the bedside with a noninvasive
approach. A recent investigation demonstrated that a
low B-line ratio in lung ultrasound suggests miscella-
neous causes of acute respiratory failure. In contrast,
left-sided pleural effusions, moderate or severe left
ventricular dysfunction and increased IVC diameter
with low variability indicated cardiogenic pulmonary
edema rather than ARDS. A scoring system showed
a remarkable area under the curve correlation [7].
Step 2: Technique and identification of normal and
abnormal signs/patterns in lung ultrasonography
with the phased array probe
The phased array pr obe allows for adequate
penetration and image depth to assess the liver or
spleen (left side), diaphragm, and lung bases when
consolidation or effusion (the other two remaining lung
ultrasound patterns) appears. Consolidation refers to
the image of a completely air-deprived lung reaching
the ultrasound characteristics of a solid organ, for
example with the same echoic properties as the liver.
Effusion physiologically refers to when there is no
fluid in the costophrenic sinuses. When fluid accu-
mulates, it appears as a “hypoechoic” space between
the base of the lung and the diaphragm (Figure 11).
The probe marker should be directed in the cephalad
position to obtain lung imaging. This orientation is iden-
tical to the linear probe as illustrated above. However,
when there is a more significant accumulation of fluid,
the hypoechoic imaging is more evident, and the
collapsed lower lobe lung takes the appearance of an
echoic, consolidated, organ (Figure 11). The nature and
quantification of pleural effusion can be accurately
assessed with lung ultrasonography. The amount of
pleural effusion can be estimated with a formula
proposed by Balik: V (mL) = 20 × Sep (mm); where
V = volume of pleural effusion and Sep = distance
between the two pleura layers [19, 20]. Semiquan-
tification, for the purpose of rapid decision making on
effusion drainage has also been proposed [21].
Fig. 11. Large right pleural effusion. The phase array probe marker
shou ld be orient ed cephala d (12 o’cloc k) . The ultrasou n d
examination should start at the right flank and slight posterior
tilting will improve the image quality of the kidney. Then, a slow
sliding in cephalad direction will facilitate the recognition of the
liver, diaphragm, large pleural effusion and to the collapsed lung
(by permission of the Mayo Foundation for Medical Education and
Research; all rights reserved)
Focused cardiac ultrasound-driven
approach to the surgical patient presenting
with arterial hypotension, shock, or cardiac
arrest
Focused echocardiography as part of FUSA should
be used in the initial assessment of patients with
undifferentiated shock (Figure 3). Furthermore, the
impact of this approach is that it increases diagnostic
accur acy and optimizes management of shock.
Although most of the evidence regarding focused
cardiac ultrasound has been obtained from the emer-
gency room and intensive care unit scenarios, causes
of shock are similar in perioperative setting. These

Perioperative focused cardiac and lung ultrasonography 49
investigations have attempted to demonstrate the
usefulness of narrowing the etiologies of shock states
and subsequent change in management [4, 22-24].
It would seem logical that new information from
diagnostic tests would lead to better clinical outcomes.
However, this is not so straightforward with the appli-
cation of focused cardiac ultrasound protocols in anes-
thesia or critical care medicine; the greatest evidence
supporting their use is currently represented by the
effective mitigation of diagnostic uncertainty [25].
More importantly, with existing evidence, a rigorous
randomized clinical trial might be considered unethical
at this time [1].
In emergency conditions such as periresuscitation,
an ultrasound-driven approach is appealing to anes-
thesiologists and/or critical care practitioners because
this tool is noninvasive and a timely assessment can
be exercised any time as point-of-care. The most
critical information obtained in cardiac arrest is the
identification of the mechanical contractility during
pulseless electrical activity (PEA) cardiac arrest. This
condition has been named “Pseudo-PEA arrest”, and
it is associated with higher survival than PEA cardiac
arrest [26]. In his study, Breitkreutz demonstrated that
the image procurement was feasible in 96% of the
204 cardiac arrest cases. Thus, it is reasonable to con-
sider that this ultrasonography applicability be incor-
porated in the advanced cardiac life support in the
future. Other authors have demonstrated similar find-
ings in the cardiac arrest setting [27, 28].
Focused cardiac ultrasound can facilitate the recog-
nition of treatable causes of cardiac arrest (cardiac
tamponade, pneumothorax, massive pulmonary em-
bolism, and severe left ventricular dysfunction) [29-31].
During the last few decades, the anesthesiology
community has demonstrated interest in the evaluation
of left ventricular function in the perioperative period.
The visual estimation of the left ventricular function
appears to be feasible, and previous studies have
showed good correlation with formal transthoracic
echocardiography by cardiology practitioners [32]. This
information can be immediately available during the
pre-anesthesia evaluation in patients that require urgent
or emergency anesthesia care [2, 3]. Moreover, pa-
tients with known systolic left ventricular dysfunction
can be reassessed anytime they present with hemo-
dynamic instability in the perioperative period.
Anesthesiologists frequently need to determine “fluid
responsiveness” in the clinical setting of perioperative
arterial hypotension. Focused cardiac ultrasound,
although not suitable for detecting fluid responsiveness
(which requires measurement of cardiac output, beyond
the capability of focused cardiac ultrasound and per-
taining to the Doppler echocardiography), is well suited
for screening of severe hypovolemia, noninvasive
estimation of central venous pressure, and of systolic
ventricular function in patients who are spontaneously
breathing. In this patient population, an IVC end-
exhala tion dia meter lower than 1 cm and small
hyperdynamic right and left ventricles (the severe
hypovolemia “triad”) should receive fluids in the clinical
setting of arterial hypotension, especially secondary to
trauma or other states that involve hypovolemia
pathophysiology (i.e., severe diarrhea, sepsis) [33].
In contrast, a more cautious interpretation of this
estimation must be taken into account for patients
receiving mechanical ventilation because the natural
tendency of more distended IVC during the respiratory
cycle and the variability of the abdominal-thoracic
pressures interplay. Thus, no reliable IVC end-expira-
tory size cutoffs are available in mechanical ventilation.
Given the current inaccuracy of the end exhalation
diameter measurement, several studies demonstrate
the usefulness of the distensibility index in passive (the
patient does not trigger the ventilator) mechanically
ventilated patients [5, 34, 35].
To date, there is scarce evidence to establish an
association between the routine utilization of focused
cardiac ultrasound and improved perioperative out-
comes. The expert consensus has been considered
invaluable given the methodological limitations of a
randomized trial. Despite this limitation, a much higher
diagnostic accuracy using focused cardiac ultrasound
has been demonstrated. Jones et al. were able to find
the etiology of shock in 80% of patients with an
ultrasound-driven approach versus 50% (without
utilization of focused cardiac ultrasound) [22].
Cowie et al. has showed the usefulness of focused
cardiac ultrasound performed by anesthesiologists in
the perioperative period. Relatively common disorders
such as aortic stenosis, mitral valve disease, and
pulmonary hypertension, which have a direct impact
in the anesthetic plan, were identified with this
perioperative approach. Up to 82% of patients required
changes in perioperative mana gement based on
focused cardiac ultrasound. Finally, most of the major
findings by anesthesiologists correlated (92% of patient
evaluations) with formal comprehensive echocardio-
gram examinations performed by cardiologists [36-38].
Another potential advantage of implementing FUSA
is its utilization on some patients who can receive a
more appropriate perioperative management of these
medical conditions (i.e., patients with unknown poor
LV function that require mechanical thrombectomy for
acute ischemic stroke). Perioperative cardiac events
can be predicted by the routine use of focused cardiac
ultrasound in noncardiac surgery [3].
Although these investigations have not shown
improved clinical outcomes, this approach certainly
facilitates the perioperative management of potential

Díaz-Gómez et al.50
high-risk surgical patients. More recently, the early goal
directed therapy utilizing invasive monotoring to guide
fluid resuscitation in septic patients has been questioned
[39-41].
Moreover, there is a growing interest in the better
characterization of the cardiovascular profile of septic
patients under echocardiography. Preliminary evidence
in the emergency department has hightlighted the value
of focused cardiac ultrasound in the suspicion, diagno-
sis, and management of septic patients [42]. In summary,
it seems quite reasonable to perform an initial ultra-
sound-driven assessment of surgical patients with acute
hemodynamic instability. With appropriate training,
more standard utilization of this technology in the
perioperative setting, and importantly, its noninvasive
nature and widespread availability, there is no doubt
that perioperative outcomes can be dramatically
improved in high-risk patients.
In Figure 12, a practical and methodical approach
to shock with FUSA is presented.
Lung ultrasound-driven approach to the
surgical patient in acute respiratory
distress
Initial assessment of perioperative patients presenti-
ng with acute respiratory insufficiency or failure should
include both cardiac and lung focused ultrasonography.
Thus, both ultrasound examinations are complementary
in the characterization of acute respiratory failure
(ARF). Furthermore, the value of this approach is
maximal when patients develop shock and ARF (see
Figures 12 and 13).
Conclusions
Focused cardiac and lung ultrasound in anesthesia
has gained acceptance among anesthesiologist and
critical care practitioners in the last decade. Its clinical
application has improved the diagnostic accuracy of
potentially life-threatening conditions in the periope-
rative period. Both modalities are complementary in
the evaluation of patients suffering from hemodynamic
instability or acute respiratory failure. In addition, the
noninvasive nature of these techniques, lack of radia-
tion, and use of consumables makes it safer and more
cost-effective for the timely care of surgical patients.
However, there is need for more robust clinical evi-
dence of clinical impact in patient care. Lastly, focused
cardiac and lung ultrasound for monitoring are far from
routine use given the limited quantitative information
obtained with them. Thus, more advanced training is
necessary in order to achieve the most useful infor-
mation from perioperative ultrasonography.
Limitations of focused ultrasonography in
anesthesia
Transthoracic echocardiography can be difficult
under certain circumstances (e.g., patients with morbid
obesity, severe chronic lung disease, and/or chest wall
deformity). Most patients have at least one “good echo
view”, and at times, only one view is technically
appropriate.
The anesthesia practitioner must also be aware of
relevant limitations when applying lung ultrasonography.
Fir s t, s u bcutaneous emp hys ema p r event s the
ultrasound beam from reaching deeper structures
(pleura). Other conditions that limit the ultrasound
examination of the lung include previous pleurodesis,
pleural calcifications, and the presence of chest tubes.
Morbidly obese or edematous patients can also be
difficult to evaluate because a great dissipation of
ultrasound energy occurs in the superficial layers.
Conflict of interest
Nothing to declare

Perioperative focused cardiac and lung ultrasonography 51
Fig. 12. Practical and methodical approach to shock with focused cardiac and lung ultrasonography
(by permission of the Mayo Foundation for Medical Education and Research; all rights reserved)

Díaz-Gómez et al.52
Fig. 13. Synopsis of lung ultrasound semiotics. Main segmental patterns are illustrated (left column) and described in their distinctive
features (right column). Normal pattern (13A), sonographic interstitial syndrome (> 3 B-lines/intercostal space) (13C) and pneumothorax
(1F) are mutually exclusive artefact-based patterns. Pleural sliding (13A) and lung pulse (13B) are representations of visceral pleural
motion (in a ventilated and a non-ventilated lung area, respectively), and are here shown using M-Mode imaging as having a different
appearance of artefacts beyond the pleural line. M-Mode provides representation over time of reflected echoes from a single scanning
line. Effusion (13C) and consolidation (13D) are image-based patterns. E: effusion; P: lung; L: liver; S: spleen; e: loculated effusion;
asterisks indicate rib shadows) (modified with permission from Minerva Anesthesiol 2012; 78: 1282-1296)

Perioperative focused cardiac and lung ultrasonography 53
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54
Ultrasonografia cardiopulmonară ţintită:
implicaţii şi aplicabilitate în perioada
perioperatorie
Rezumat
Ultrasonografia cardiopulmonară ţintită în anestezie
(FUSA) poate reprezenta atât un instrument diagnostic
şi procedural, cât şi un instrument de monitorizare care
este de real folos în îngrijirea perioperatorie a pacienţilor
chirurgicali. Utilizarea acestei metode este recomandată
în practica anestezică şi de terapie intensivă. Deşi în
prezent există bariere semnificative în utilizarea mai largă
a metodei, dovezile privind utilitatea acesteia continuă să
apară, astfel încât să asistăm la stabilirea ei ca standard
de îngrijire în perioada perioperatorie.
În prezent, cele mai frecvente aplicaţii ale FUSA sunt
reprezentate de ghidarea şi descrierea şocului perioperator
(cord pulmonar acut, insuficienţă ventriculară stângă,
tamponadă cardiacă şi hipovolemie), precum şi de insufi-
cienţa respiratorie acută (pneumotorace, edem pulmonar
acut, colecţii pleurale masive, atelectazii masive).
Acurateţea înaltă a diagnosticului în toate aceste situaţii
clinice face importantă utilizarea FUSA în perioada
perioperatorie. Mai mult decât atât, FUSA are aplicaţii şi
în alte sfere ale practicii anestezice, precum manage-
mentul căii aeriene şi evaluarea conţinutului gastric în
urgenţele chirurgicale.
Cuvinte cheie: ultrasonografie cardiacă ţintită,
ultrasonografie pulmonară, şoc, hipoxemie