Table 4

FoCUS I-AIM framework for the regional anesthesiologist

PathologyClinical indicationAcquisition—optimal FoCUS view(s)InterpretationMedical decision-making
Local anesthetic systemic toxicity (LAST)Delayed onset of hemodynamic instability following neuraxial or PNB in a patient with no known cardiac disease (±arrhythmias)PSAX
Alternative Acceptable Views:
Sluggish, poorly contracting and potential dyssynchronous LV
Provide hemodynamic support (±inotropes or vasopressors)
Follow LAST guidelines, including the use of lipid emulsion
Aortic stenosisUrgent or emergent surgery (eg, hip fracture surgery) with inadequate medical workup and an audible systolic murmur on auscultationPLAX
PSAX at the level of AV*
PLAX and PSAX at level of AV*
↓AV cusp mobility
↑ AV cusp thickness/calcification
Urgent Case
Formal TTE and cardiology consultation
Emergent case
Adjust perioperative management:+arterial line, maintain hemodynamics with vasopressors±inotropes throughout induction, escalate postoperative care to stepdown or ICU
HypovolemiaUrgent or emergent surgery with concern for hypovolemia (eg, trauma patient or ESRD following dialysis)SCIVC
IVC diameter<1.5 cm, >50% collapse with ‘kissing wall sign’
Hyperdynamic LV with underfilled end-diastolic volume and end-systolic ‘touching’ of the myocardium
Note: Emptying depends on afterload
Fluid resuscitation prior to induction
Consider gradual induction with epidural over a subarachnoid block
Pulmonary embolism (PE)Suspected massive PE in high-risk patient population (eg, orthopedics or trauma patient)PSAX
A4C or SC4C
D-shaped septal shift, RV>LV
A4C or SC4C
RV and RA dilation>LV
Intraventricular septal bowing toward LV during systole
Cardiopulmonary resuscitation when necessary
Initiate thrombolytic therapy and/or embolectomy
  • *Advanced view not discussed in the recommendations.

  • A4C, apical four-chamber view; AV, aortic valve; ESRD, end-stage renal disease; FoCUS, focused cardiac ultrasound; I-AIM, Indication, Acquisition, Interpretation, and Medical Decision-Making Framework; ICU, intensive care unit; IVC, inferior vena cava view; LAST, local anesthetic systemic toxicity; LV, left ventricle; PLAX, parasternal long axis view; PNB, peripheral nerve block; PSAX, parasternal short axis view; RA, right atrium; RV, right ventricle; SC4C, subcostal four-chamber view; SCIVC, subcostal inferior vena cava view; TTE, transthoracic echocardiogram.