INTERNATIONAL NEUROANESTHESIA NEWS

Use of TCD for Neuromonitoring in India and the Role of AIIMS TCD Workshop

Girija Prasad Rath, MBBS, MD, DM
Department of Neuroanesthesiology and Critical Care
Neurosciences Center
All India Institute of Medical Sciences (AIIMS)
New Delhi, India

During the last decade, the popularity of Transcranial Doppler (TCD) ultrasonography in India as a neuromonitoring modality has significantly increased. It is mainly utilized in the settings of neurocritical care. Currently, the availability of TCD is limited to a few advanced neuro-centers, and other centers are finding this gadget interesting for patient monitoring. However, the utility of this technology has been limited to insonation of an intracranial artery of anterior circulation, mainly assessment of middle cerebral artery (MCA) flow velocity as a part of diagnosis and monitoring of cerebral vasospasm. It is possibly due to lack of any structured curriculum on neurosonology in India. Of late, the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) took the initiative of training its members in TCD as a part of “Neuromonitoring Workshop” during annual scientific meetings. However, a couple of hours workshop along with other monitoring modalities remained insufficient for understanding the practical use and interpretation of TCD. In order to impart appropriate training on TCD among the interested participants (mainly anesthesiologists), a full-day workshop on Transcranial Doppler (TCD) ultrasonography was organized on October 5, 2017 at the Conference Hall of Neurosciences Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India. The idea was to train anesthesiologists providing dedicated neuroanesthesia and neurocritical services who would learn both basic and advanced TCD. It was also expected of them to help dissipate the utility of TCD further among their colleagues regardless of speciality.

Dr. Deepak Sharma, Professor and Division Chief of Neuroanesthesiology and Perioperative Neurosciences and Educational Director, Cerebrovascular Laboratory, and Ms. Anne Moore, Supervisor at Cerebrovascular Laboratory from HMC, UW, Seattle, USA along with Dr. Girija Prasad Rath, Professor of Neuroanesthesiology and Critical Care at AIIMS, New Delhi, India were the instructors for this workshop. The first comprehensive workshop on TCD ultrasonography in India, it consisted of interactive lectures, live demonstrations of basic examinations, hands-on training, video demonstrations and case discussions on advanced uses of TCD. The number of participants was restricted to 24, and they were allocated to five skill stations in order to provide adequate hands-on experience with volunteers.

Figure 1: Demonstration of a basic TCD examination on a volunteer.

At the beginning, Professor Girija Rath welcomed the faculty from abroad and the participants and highlighted the possible impact of such a workshop in Indian context. Professor Deepak Sharma gave an overview of the application of the TCD. Ms. Moore demonstrated basic TCD examinations on a volunteer and shared practical tips with the participants (Figure 1). There was a series of video demonstrations cum lectures with two hands-on sessions inbetween for the participant. During the first hands-on session, the participants were encouraged to insonate all the intracranial vessels with faculty guidance and successful insonations were recorded on the “Learning Passport”. This was followed by a second hands-on session (Reporting TCD) where the participants were encouraged to perform a basic TCD examination on volunteers and report in a prepared format. The lectures included “Cerebrovascular Anatomy and the Principles of TCD”, “Performing Basic TCD Examination”, “Waveform Analysis”, “Reporting of TCD Examination”, “Cerebral Autoregulation and CO2 Reactivity”, “Emboli Monitoring” and “TCD for Carotid Endarterectomy, Cerebral Vasospasm, and Cerebral Circulatory Arrest”. Dr. Sharma also discussed some case scenarios interacting with the participants and involving them in the interpretations. At the end of the eight-hour workshop, there was a group discussion when participants had the opportunity to ask further questions. The participants completed an online evaluation of the workshop over the next two weeks. (Figure 2). More than 80% of the participants felt the duration of workshop and the lectures were “just right”; 88% termed the quality of lectures to be “very good to excellent”. More than 70% of the participants could insonate all expected intracranial vessels, whereas everyone could insonate the middle cerebral artery. Ninety-four percent of participants felt the objectives of the workshop were met and all of them recommended this type of workshop to other interested participants. With this feedback, we feel that full-day workshops on TCD may actually help participants to understand use of TCD in a better way, at least in the Indian context.