Perioperative point-of-care ultrasonography: the past and the future are in anesthesiologists' hands.

I N this issue of ANESTHESIOLOGY, Ueda et al. report two cases in which point-of-care ultrasonography led to the rapid intraoperative diagnosis of pneumothorax. In recent years there has been a dramatic increase in the utilization of ultrasound for real-time guidance of clinical decision-making and procedures. A growing body of evidence demonstrates the benefits of this change in practice. The scenarios described in this issue’s case report highlight anesthesiologists’ application of an improved method for diagnosis of intraoperative pneumothorax. Furthermore, they prompt the question: “What role should anesthesiologists play in the burgeoning field of point-of-care perioperative ultrasonography?” To answer that question about the future, we must delve into the past. Anesthesiologists have been instrumental in the development of perioperative ultrasound over the last 30 yr. Notable success stories include intraoperative transesophageal echocardiography, ultrasound-guided vascular access, and ultrasound-guided regional anesthesia. Cardiologists initially developed transesophageal echocardiography in the early 1980s for imaging of cardiac structures not well visualized on transthoracic echocardiography. By the late 1980s, cardiac anesthesiologists recognized the potential effect of intraoperative echocardiography on cardiac surgery. Initially anesthesiologists depended on cardiologists for transesophageal echocardiography image acquisition and interpretation, but subsequently gained the skills to perform and interpret intraoperative transesophageal echocardiography independently. Much advancement in transesophageal echocardiography is attributable to the ingenuity of anesthesiologists who sought to improve the care of cardiac surgical patients. More recently, critical care anesthesiologists have helped lead the development of point-of-care transthoracic echocardiography in the perioperative period. Focused transthoracic echocardiography allows clinicians to rapidly and noninvasively answer important questions about cardiac function and pathology. Ultrasound-guided vascular access was first described in the late 1970s and has evolved into a widely recommended method for improving patient safety.* In 1978, Ullman and Stoelting described the use of a Doppler device for localization of the internal jugular vein. Legler and Nugent published a small series in 1984 that showed an increased likelihood of first-pass success during internal jugular cannulation using Doppler technology. By the 1990s, anesthesiologists were using ultrasound for imaging of neck anatomy during the placement of internal jugular lines. Anesthesiologists’ use of ultrasound guidance for vascular access increased tremendously in the past decade and in 2011 it is a common component of anesthesiology residency training. Clinicians who use ultrasound for central venous access also successfully apply similar techniques to aid in the placement of difficult arterial or peripheral venous lines. Anesthesiologists followed a similar time course in the development of ultrasound guidance for regional anesthesia. A 1978 article by la Grange et al. described Doppler localization of the subclavian artery before performance of a supraclavicular brachial plexus block. Eleven years later, Ting and Sivagnanaratnam reported real-time imaging of local anesthetic spread around the axillary brachial plexus during 10 nerve blocks. In the 22 yr since that report, ultrasound guidance for regional anesthesia has developed into a major component of routine anesthesia practice, thanks in large part to a group of dedicated pioneer anesthesiologists who have fostered the field and ensured its success. Photograph: J. P. Rathmell.