The usefulness of the transesophageal Doppler in the anesthetic management of Morgagni hernia repair - A case report

Morgagni hernia in adults is a rare condition and is associated with complications such as recurrent chest infections, respiratory failure and cardiac tamponade. Its correction represents an anesthetic challenge. Intraoperative esophageal Doppler provides important information in real time about the patient’s cardiac function and vascular filling, aiding in decision making by the anesthesiologist. We report a case of a 70–year–old woman, ASA Physical Status–III, and presented with chest pain, dyspnea and hypoxemia. Her chest x-ray revealed opacification of 2/3 of the left hemithorax and 1/2 of the right. Computed tomography confirmed a bilateral Morgagni hernia. The patient underwent immediate corrective surgery. Intraoperative cardiovascular function was monitored with esophageal Doppler. Compression and decompression of thoracic structures produces enormous hemodynamic and respiratory impact. After herniated contents removal it showed an increase in systolic volume and cardiac index and a correction of flow time. Transient arterial hypotension was verified, requiring fluid therapy and vasopressor support. Diaphragmatic defect was corrected and general hemodynamic stabilization was achieved. Patient was discharged asymptomatic. The esophageal Doppler was important in this case because it allowed us to measure fundamental hemodynamic variables in real time, such as cardiac index or systolic volume, and to subsequently act accordingly. Key words: Esophageal; Doppler; Morgagni hernia; Anesthesia Citation: Babo NM, Monteiro MT, Santos AB, Carreira CR. The usefulness of the transesophageal Doppler in the anesthetic management of Morgagni hernia repair - A case report. Anaesth pain intensive care 2021;25(2):206-211. DOI: 10.35975/apic.v25i2.1467 Received: 19 November 2020, Reviewed: 22 December 2020, Accepted: 12 January 2021

Estimation of cardiac output variations induced by hemodynamic interventions using multi-beat analysis of arterial waveform: a comparative off-line study with transesophageal Doppler method during non-cardiac surgery

Multi-beat analysis (MBA) of the radial arterial pressure (AP) waveform is a new method that may improve cardiac output (CO) estimation via modelling of the confounding arterial wave reflection. We evaluated the precision and accuracy using the trending ability of the MBA method to estimate absolute CO and variations (ΔCO) during hemodynamic challenges. We reviewed the hemodynamic challenges (fluid challenge or vasopressors) performed when intra-operative hypotension occurred during non-cardiac surgery. The CO was calculated offline using transesophageal Doppler (TED) waveform (COTED) or via application of the MBA algorithm onto the AP waveform (COMBA) before and after hemodynamic challenges. We evaluated the precision and the accuracy according to the Bland & Altman method. We also assessed the trending ability of the MBA by evaluating the percentage of concordance with 15% exclusion zone between ΔCOMBA and ΔCOTED. A non-inferiority margin was set at 87.5%. Among the 58 patients included, 23 (40%) received at least 1 fluid challenge, and 46 (81%) received at least 1 bolus of vasopressors. Before treatment, the COTED was 5.3 (IQR [4.1–8.1]) l min−1, and the COMBA was 4.1 (IQR [3–5.4]) l min−1. The agreement between COTED and COMBA was poor with a 70% percentage error. The bias and lower and upper limits of agreement between COTED and COMBA were 0.9 (CI95 = 0.82 to 1.07) l min−1, −2.8 (CI95 = −2.71 to−2.96) l min−1 and 4.7 (CI95 = 4.61 to 4.86) l min−1, respectively. After hemodynamic challenge, the percentage of concordance (PC) with 15% exclusion zone for ΔCO was 93 (CI97.5 = 90 to 97)%. In this retrospective offline analysis, the accuracy, limits of agreements and percentage error between TED and MBA for the absolute estimation of CO were poor, but the MBA could adequately track induced CO variations measured by TED. The MBA needs further evaluation in prospective studies to confirm those results in clinical practice conditions.