 Hello, my name is Paolo Press. Thank you to the organizing committee of the 20th annual Toronto Period of Tea Symposium for the invitation to participate this year. Again, this year with a very innovative program, including point-of-care ultrasound by TEE. Today I'm going to be speaking about the use of point-of-care tea in the period-operative setting for rescue purposes and cardiac arrest. To start with, to disclose any conflict of interest, my only conflict of interest will be that I'm part of the faculty of the resuscitative tea workshop. I don't get any remuneration for it, and I'm part of the collaborative group of the resuscitative tea as well, but again with no remuneration. Today we're going to be speaking about the role of the rescue tea in the operating room, review some of the literature that is available on that topic, and also focus and understand a little bit more about the role specifically for resuscitation during cardiac arrest of a tea. Now, what's a rescue tea? Like we know there's a basic tea study and it's been described by the guidelines published in 2013 by ASC, and this basic tea exam, it's with 11 views in order to diagnose and do a basic assessment different from the comprehensive period-operative tea assessment, which is the one often done in the cardiovascular operating room done by cardiovascular anesthesiologists. However, this basic tea is meant to be or not necessarily done in the cardiovascular operating room by cardiovascular anesthesiologists. So what is rescue tea then? So the way, although there's no very standardized definition of what rescue tea is, the way that I like to think about it is this is a cover from one of my favorite rock albums from the 90s by Nine Inch Nails, and it's called the Dunward Spiral, and this is the way I like to think about resuscitated pocus or resuscitated tea in the operating room where we often get cold when there's a patient who suddenly becomes hemorrhage unstable or have any other major crisis involving oxygenation or ventilation and quickly gets into a Dunward Spiral, and some of this time there's no sometimes there's no clear etiology or clear cause of why this is happening, and it's very undifferentiated, and that's when the role for resuscitated tea has a good importance because it can bring and answer questions to try to identify those etiologies in an undifferentiated shock patient. So when we compare basic to rescue tea, although again there's no standardized definition and if you read literature, different groups do different things in terms of what views they include in their rescue tea protocol or resuscitated tea protocol, but a different from the 11 or 16 views from the basic comprehensive assessment, it's usually between four and six views that have been described as part of the rescue TEE exam, and these views include the bi-cable view, the mediasophageal four chamber, the mediasophageal long axis, a trans-gastric short axis view, and some additional views that other groups include such as the ascending aorta and the RV inflow outflow, depending on which pathology they're looking for, and it's very important to remember that the intention of doing a rescue tea study or a resuscitated tea study is to help confirm life-run and situation diagnosis and ruling or rule out conditions such as pericardial effusion that is causing cardiac tamponade or a severe RV or LV dysfunction that could explain the shock, as well as major pathology from the great vessels such as artery dissection or a saddle pulmonary embolism as an example, and it's not meant to be do a comprehensive study, it's meant to help you answer these important questions in a very timely fashion to help you guide your resuscitation and management of these patients. There's been a few descriptions of different protocols, however not many are published in the literature, this is one of the few that's been developed and implemented in the perioperative setting by anesthesiologists and it was done by the group at Mass General Hospital in Boston and they developed this rescue tea team that consists on a team either at a cardiac anesthesiology fellow or a senior resident from anesthesiology will cover this rescue tea service after being certified and properly trained and they would review these images with an in-house cardiac anesthesiologist to help making the diagnosis and guiding the decisions. This team was triggered, the usual triggers were patients with severe hypertension, cardiac arrest, severe hypoxemia with no clear etiology and they will focus doing five use. They were able to follow and collect the data from a series of patients, almost 50 patients and they look at what were the indications for this study and if it during the exam would help them manage and diagnose these patients and from the 48 patients they were able to shown that almost 80% of these patients did actually had a change in management after the findings in the tea. Most of these findings were related to severe hypovolemia that helped guided the further resuscitation with a volume expansion but other treatments that were initiated or changed were the use of inotropic support using different type of a suppressors or using other type of investigations or treatments such as taking the patient to the cat lab putting an interactive balloon pump ECMO or pericardial drainage. So it was shown that a use of these patients in the non-cardiac setting using this resuscitative tea helped them guide them in managing these patients for the shot. Similar study was done recently in London, Ontario by a group in the intensive care unit in the med surgical ICU where they use a protocol with only four views and they look at patients who were in severe shock or severe hypoxemia with not clear etiology and the findings were quite consistent with the mass general group. They also find about between 70 and 80% of the time is in or doing a resuscitative tea did ended and changing the management or making new decisions for the management of these patients. They were able to collect this data in 274 patients and again a lot of these findings were more aggressive volume resuscitation, initiation or changing of inotropic suppressors and other things like changes in the ventilation, drainage, her surgical control. So both observational studies have clearly shown that there is a role for the use of emergency tea outside of the cardiac OR and both the non-cardiac perioperative setting but also in the critical ill patients who are severely unstable without undifferentiated conditions. This is a systematic review that it shows you fortunately it was published before this large two series were published but what is important is it collects the data from several small observational studies and case reports and case series where they use the resuscitative tea or rescue tea for non-cardiac surgery and it was done both in the context of liver transplant, multisystem, multi-organ transplant, trauma patients and they most of these series or other data is quite small to make conclusions and make significant contributions to make a systematic review analysis. When you look at most of the individual studies they show that there was a difference in terms of the management of these patients and it helped with the diagnosis and what is also important is that these studies some of them or most of them did report if there were any adverse events with the use of transesophageal echo and most of them did not report any side effects or any adverse events and the ones that it did it were a minor adverse events such as minor oral bleeding, discomfort from the patients after the use of tea but no significant complications such as esophageal perforation or other mechanical complications. So looking at this data although it's limited and it's not too many studies around and the ICU and peruptive this setting although there's more done in the emergency department setting in the context of a cardiac arrest but they all have a similar conclusion in terms that it can be a very useful tool and bring in diagnosis and differentiate a shock patient and guiding helping guiding the management. Now if you ask me like why would you bother doing TE where we're getting very good at doing Pocos TTE this is the answer like sometimes and a lot of the time these patients that are critical have not very good windows and that can be related to the fact that they are in positive pressure they are they have body habits that are difficult to assess or position there or even more important for us in the operating room where the a lot of the time the surgical drapes are covering most of the chest so we don't even have access to the chest to the skin therefore TTE offers the opportunity the patients are already intubated under a general anesthetic sedated and with an airway so it's easier technically to put a TTE probe and get a good assessment and good windows to assess and looking for the answers finding the answers that we're looking for. So what I'm going to do now is I'm going to present a series of cases that we have done over the past few years where TTE or Rescuti did make or was part of a change in the management of the patients. So this is the first case where this is a elective c-section and an uncomplicated pregnancy and after the baby was delivered the patient became in severe shock with decreased level of consciousness she needed to be intubated and was in a pre-array situation that required advanced resuscitation. It was not very clear etiology there was no signs of bleeding there was again uncomplicated pregnancy no other anesthetic complications and so after a few minutes of resuscitation without not a very good response we would call and put a TTE probe and what we saw was somehow consistent with the dilagum increased the size of the RV cavity and with severe RV dysfunction and an empty LV as well so in the context of the clinical scenario and the findings both of the Amidus of Agilophore with the dilated RV and even some what it looked like some anatomical abnormalities inside the RV this could have this brought the possibility of being amniotic fluid embolism causing severe RV dysfunction and the severe shock. This patient eventually had to go into a VA ECMO for mechanical support and did well and had a good outcome at the very end but it was it was a good example of how to help them or help us making the diagnosis. This is another case where a patient who came comes in for a young patient on the mid 40s with a laprod for an emergency laprodomy for a small bowel obstruction and during the intrap and after induction of anesthesia becomes severely hypertensive and not really responding to the initial management of fluid and pressers started on our norepine and aphid infusion with again not very a good response. Serical dreads were on so they were not able to put a pocus TTE so they asked us to do a rescue TTE. When we did the TTE it was it was we noted that there was quite a bit of hypertrophy of the LV H and septum and asymmetric with what it was seems to be a sigmoid septum and there was some what it looked like a decreased diameter or decrease of the LVOT with the possibility of doing a dynamic LVOT obstruction. We put color on we could see that there was acceleration of flow through the LVOT as well as MR which was consistent with SAM and dynamic LVOT obstruction. This finding help managing the patient with further resuscitation with volume decreasing the heart rate and pure base of pressers and eventually the patient got out of shock and was adequately resuscitated to continue with the surgery. Another example where we're a large trauma center we get a ferment of major traumas and this is a patient who had a multi-system trauma days before he was in the ICU intubated with a previous laparotomy and now has come back to the operating room for fixation of his multiple MSK injuries during the surgery he became again very unstable in terms of shock no obvious source of bleeding and no other signs of other injuries or other explanation why suddenly became hypotensive so T was asked to be done and we noted that again there was a although a hyperdynamic that would look like how the RV was dilated and on the short axis and the transgathric view we could see that there was a clear dilation of the RV with some flattening on the interventricular septum all consistent with it looked to be a acute RV failure and in the context of the the patient plus hypoxemia as well it was thought that we could be related to a major or a massive pulmonary embolism so eventually after further resuscitation with a vasopressor patient was taken to the CT scanner at a CTPA and indeed show a massive pulmonary embolism that require management with thrombolitis another case that illustrated the role of rescue T this is a patient who had a triple A repair uh which was completely uneventful got excavated at the end of the case went to the ICU and hours later started becoming hypotensive and increasing and rising lactate uh initially thought by the surgical team that it could be related to uh bowel schemia uh however a patient was taken back to the operating room for an emergency laparotomy and did not show any changes in the bowel and given the fibers to still quite hypotensive and portive responsive to the resuscitation and still rise in lactate decided to insert a T probe and what did is shown as an intramural dissection of the ascending order to extending all the way down likely a retrograde dissection from the previous clamp from the triple A repair so eventually this patient needed to have a full replacement of the ascending and this is a good example how prompt real time point of care T really made a change otherwise would have been a very difficult diagnosis to make and it probably would have been delayed until the patient would have been back to the ICU and not getting better probably got a full CT and they would have seen this and finally to finish with the cases this is another case patient who had a thoracolumbar laminectomy in the context of severe scoliosis uneventful otherwise medically perfectly healthy and patient was good after induction of anesthetic good and supine when it was prone it became severely hypotensive not a clear reason why there was no source of bleeding no medication error no signs of an aphrolaxis so it was decided to bring the patient back to supine position to further resuscitate and with further resuscitation he really improved and it was wing off all the medications so the situation was to continue with the surgery and once the patient was prone again it became severely unstable again with severe hypotension refractory to the usual vasopressor so it was not clear why that all you over this was so T was inserted and we could know that when he was in the prone position there was a mechanical dynamic obstruction of the RVOT and decreasing the size and compressing the ribentricle likely related to the fact that these severe scoliosis and change in the ribcage and thoracic cavity it was making it was a mechanical obstruction when he was going in prone position so after readjusting the ballsters filling up with more volume the shock resolved and the surgery was able to continue without any further problems so all these cases illustrate the utility of having a rescue T available and in the context of non-carry of surgery and some of them a couple of them were done by non-carry of anesthesiologists that were able to provide with the basic views to make and help the decisions to guide the management of these patients now the other thing that I want to really focus on or want to mention is was the use of the role the increasing role of T during cardiac arrest and this work has been pivoted and developed mostly by the emergency physicians and they have been using resuscitative T for the last few years and initially it was more like a diagnostic role to identify the usual Hs and Ts but now there's been more uses being described such as it can help you with procedures such as cannulation of ECLS or cannulation of other central axis and now there's also a role that has been identified that can help you enhance and optimize the quality of chest compressions during the during the resuscitation and even a prognostic role when it's able to identify different causes who have a very high mortality and very poor outcomes in terms of after resuscitation now again you will ask me why would you do T and because like Pocosti T has been described to be useful and it's been incorporated in the ECLS guidelines for a few years now however the caveat is one of the caveats is that it's found to be that the T T Pocosts sometimes have delayed the chest compression or interrupt the chest compression it's very important to remember that despite having very good technologies we have to stick with the basics when we're running an ECLS code and it's good chest compressions and early defibrillations the only two interventions that are shown that really improve the outcomes of this patient having said that so they sometimes Pocosti T can interrupt and can be in the way of these interventions having said that as transit of a ELECO because it's outside of chess it's not in the way of CPR it could offer LPP potential good for cardiac resuscitation and there is in fact a small study where they compare the use of T versus T T and pulse checks and T was the one who found interrupt the last and delayed the last the quality of chest compression and initiation of chest compression because it's again it's away from the chest it's somebody else dedicated of doing that while the ongoing resuscitation is happening and just to mention again like the idea during the cardiac arrest is helping with the diagnosis of the potential reversible causes and specifically things like severe hypovolemia severe pericardial tamponade, cardiac tamponade from pericardial effusion however there's also a new entity that's being described as pseudo PEA and is helps with the diagnosis of a very fine buffet that is not identifiable in the ECG and this pseudo PEA what it means is that there's some electrical activity where there's no palpable pulse but when the T is done there's some organized electrical activity that tells you that there are some activity that will probably require higher support from inotropes and base oppressors to restore the function and this is an example of a pseudo PEA this is a patient who had a cardiac arrest a PEA arrest there was no palpable pulse but when we put a T probe you could see that there is although very poor contractility there is some organized activity that with the help of more inotropes and higher doses of inotrope it could respond better and the resuscitation and this is just to highlight there's different studies done mostly in the intrahospital cardiac arrest scenario both intraoperative and outside of the operating room and they have shown they all have shown that there's utility in terms of diagnosis and the cause of the arrest now the new or the most recent application has been studies how to identify the quality of CPR and we do that because there's the maximal compression area where the CPR should be doing in the RV and LV and avoiding compressing the LVOT to avoid impeding the outflow or the stroke volume going through the arctic valve and it's interesting to see that there's been studies done with the looking at this and we have then been identified that it's 50 to 60 percent of the times the CPR is actually not done in the proper space and that's actually occluding the RVOT so now it's become a good way to assess the quality of the CPR and maybe changing the position of CPR to optimize the output during CPR and this is an example of a case we had where CPR ongoing and you can clearly see how it was done properly because the RVOT and LV are the one who have been compressed and you can see that the LVOT is free the arctic valve is open and when we put colored up we could see that there's a actually flow across the arctic valve so again this is an example of how the role of the it could be good during CPR and it's the reason why it's become and there's been guidelines developed for it mostly by the emergency physicians and in terms of training it's been shown that it's doing a simulation and and a quick or short training in the operating room with cardiac anesthesia has shown that it gives you the skills to obtain these basic four or five views and able to identify those life-threatening situations. There is even a way now to get certified for more basic D and in fact in our modern group we have two non-cardiac anesthesia that has been certified and trained for this and they are able to help and diagnose all these conditions so I encourage you to go and get trained and to take home messages I would say rescue D definitely can change your management it's has a very important role during cardiac arrest and here's here to stay here's our my email if any further questions and my email my twitter account if you also want to contact thank you again for the invitation