March 8, 2001


Evaluation of transesophageal echocardiography for diagnosis of traumatic aortic injury
Goarin JP, Cluzel P, Gosgnach M, Lamine K, Coriat P, Riou B.
Anesthesiology 2000;93:1373-1377

Commentary by Katherine Grichnik, M.D.

[see abstract below]

The authors evaluated the use of transesophageal echocardiography (TEE) for diagnosis of traumatic aortic injury (TAI). The "gold standard" for diagnosis of TAI has been aortography, but this may be cumbersome or difficult to perform in the acute setting. TEE has been advocated as being as good or better than aortography in the diagnosis of TAI TEE has the advantage of being a noninvasive procedure that can be performed at the bedside. Additional information useful information that can be obtained from the TEE includes evaluation of cardiac function and filling status. However, the adoption of TEE as the gold standard has been slow. This study adds to the increasing evidence that TEE could be used independently to diagnose and direct management of TAI, especially since minor TAI (such as an intimal flap and/or an intramural hematoma) can be managed well with nonsurgical or medical treatment. Clearly, there is a need for a diagnostic modality that can distinguish minor from major TAI.

This lengthy study (9 years) included 209 of 1890 patients admitted with blunt trauma. The study inclusion criteria were clinical signs consistent with the possibility of TAI, including a widened mediastinum and/or a sudden deceleration injury. Of the 209, one went immediately to surgery due to cardiac arrest and died intraoperatively. Of the remaining 208, all underwent TEE and most underwent aortography or spiral CT scan as well. 42 patients (20% of those with blunt trauma and a clinical sign for TAI) were diagnosed with TAI.

TEE was able to diagnose not only major TAI but also minor TAI such as an intimal flap and/or an intramural hematoma. The patients were divided into groups based on the TEE according to clinical implication. Group 1 patients had minor TAI as described above. The clinical implication was medical treatment. Group 2 patients had TAI with subadvential rupture (with medial injury or modification of the geometry of the aorta, with or without hemomediastinum). The clinical implication was the need for immediate or delayed surgery. Group 3 patients had major TAI with the clinical implication of needing immediate surgery. Major TAIs were determined to be Groups 2 and 3 and minor TAIs were in Group 1.

Aortography was found to be less accurate than TEE for diagnosis of TAI as it could not diagnose minor TAI. If considering only major TAI (Groups 2 and 3), aortography and TEE were found to be equivalent in the ability to diagnose TAI. TEE was negative in one patient with a positive angiogram and angiography was negative in one patient with a positive TEE.

This interesting study adds to the accumulating evidence that TEE is as good or better than radiographic imaging of the aorta to diagnose and then manage TAIs. TAI is not a frequent occurrence and the authors are to be commended for a 9-year study to gather enough patients to be able to draw meaningful conclusions. This study reports a high sensitivity and specificity for TEE, unlike some previous studies with lower subject numbers. The benefit of TEE include its speed of diagnosis, the ability to examine cardiac function and volume status and its relatively noninvasiveness. Further, minor TAI was diagnosed only by TEE. Risks of TEE are the inability to see (and thus may not diagnose) the supraaortic vessels which can be injured concurrently. Other risks of TEE (such as esophageal trauma) have been well described in other articles.

This author was privileged to recently hear a lecture by Dr. Daniel Thys, President of the Society for Cardiovascular Anesthesiology. His lecture was about the role of TEE in perioperative medicine. In the lecture, he challenged all anesthesiologists to become facile with TEE as its use is becoming more common in and out of the OR. This author believes that this study is yet another example of how our skills are being appreciated outside of the OR and how we can make an impact as perioperative physicians.

ABSTRACT

An Assessment of the Value of Intraperitoneal Meperidine for Analgesia Postlaparoscipic Tubal Ligation

AUTHORS:
Colbert ST, Moran K, O’Hanlon DM, Chambers F, McKenna P, Moriarty DC, Blunnie WP.

SOURCE:
Anesth Analg 2000;91:667-70.

ABSTRACT:
Patients undergoing laparoscopic procedures may experience postoperative pain. The intraperitoneal (IP) administration of drugs is controversial but has proven effective in some studies for the relief of postoperative pain. However, some investigators have not been able to confirm the analgesic efficacy of IP local anesthetics. The administration of IP opioids for the relief of postoperative pain has received little attention. At the end of laparoscopic tubal ligation, 100 patients received 80 mL of 0.125% bupivacaine with 1:200,000 epinephrine IP and 50 mg of meperidine either IP or IM. Postoperative pain scores were measured at rest and with movement. Pain scores were significantly lower in the group receiving the IP meperidine both at rest (P: < 0.01) and with movement (P: <0.05). We conclude that the combination of intraperitoneal bupivacaine and intraperitoneal meperidine was better than the combination of IP bupivacaine and IM meperidine for postoperative analgesia in patients undergoing laparoscopic tubal ligation. IMPLICATIONS: The combination of bupivacaine and meperidine delivered to the intraperitoneal cavity proved superior to equivalent doses of intraperitoneal bupivacaine and IM meperidine for postoperative pain relief in patients undergoing laparoscopic tubal ligation. Intraperitoneal delivery of analgesia proved effective in this study and merits further study and more widespread use.