Safety and Pitfalls of TEE

Tips and Tricks to Deal with It

Amiliana M Soesanto, MD
Division of Non Invasive and Cardiac Imaging,
Dept Cardiology and Vascular Medicine,
Faculty of Medicine, University of Indonesia,
National Cardiovascular Center Harapan Kita
 Performing TEE
TEE is a semi invasive procedure

It considered safe

Appropriateness of The Procedure

It carries certain risks and complications could sometimes happen

Good preparation and safety procedure have to be undertaken

risk vs benefit
INDICATIONS

J Am Soc Echocardiogr 2013;26:921-64

APPROPRIATNESS

J Am Soc Echocardiogr 2013;26:921-64

 Contra Indication

Absolute Relative
1. History of radiation to neck &
1. Perforated viscus mediastinum
2. Esophageal stricture 2. History of GI surgery
3. Recent upper GI bleeding
3. Esophageal tumor 4. Barrets Esophagus
5. History of dysphagia
4. Esophageal perforation,
6. Restriction of neck mobility
laceration 7. Symptomatic hiatal hernia
8. Esophageal varices
5. Esophageal diverticulum
9. Coagulopathy,
thrombocytopenia
6. Active Upper GI bleeding
10. Active esophagitis
11. Active peptic ulcer disease
 Complication
Complication Diagnosis TEE Intraoperatif TEE
Overall complication rate 0.18-2.8% 0.2 %
mortality <0.01-0.02% 0%
Major morbidity 0.2 % 0.1-2%
Major bleeding <0.01% 0.03-0.8%
Esophageal perforation < 0.01% 0 0.3%
Arrhythmia 0.06-0.3%
Heart failure 0.05%
Tracheal intubation 0.02%
Laryngospasm 0.14%
Dysphagia 1.8%
Hoarseness 12%
Bronchospasm 0.06-0.07%

J Am Soc Echocardiogr 2013;26:921-64

 PREPARING THE PATIENT

Knowing the patients

1.The purpose of the procedure

2.Review the indication and appropriateness for TEE

3.Review the history and examine the pts thoroughly

4.Screen for other comorbidities TIPS : Provide list of information needed

5.Check for patients medication TIPS : Provide list of certain medication

affected the procedure (anticoagulant, not taken usual medication)

6.Obtain informed consent explain how and why the procedure done

7.Check for the patient general preparation

 Patients General Preparation

1. No food for a minimum 6 hrs, no other intake for 3 hrs before

procedure explain what the consequencies

2. No anticoagulation for the last few days

Warfarin : INR less than 2 (no guidelines)

Dabigatran (Pradaxa) : 1-2 days (depend on renal function)

Rivaroxaban (Xarelto) : 1-2 days (depend on renal function)

3. IV access for emergency situation

4. Remove dental prosthesis

 Logistics and Staffs

1. One assistant monitoring, suction and sono- graphic contrast;

2. A fully stocked resuscitation trolley with cardioverter/defibrillator

3. Measure to give sedation, if required

 Logistics
1. Syringe pumps and a three way taps , if required

2. Oxygen, suction, pulse oximetry, an automated

blood pressure and heart rate monitoring device.

3. Local anesthetic agent, tongue spatula

4. Probe storage
 Patient preparation
(prior to probe insertion)

Patients discomfort is common, especially without sedation

Some techniques for inserting the probe

Understand the possible injury during probe insertion

Does anesthesia needed ?

Topical anaesthesia :

gel, spray, gargle, lozenge : benzocain, lidocain

check if the effect has occurred

Sedative and anesthetic agents

 Probe preparation
(prior to intubation)

1. Probe : neutral position (unlocked)

2. Mouth guard :

Place in the mouth prior to probe insertion

Place in the mouth after probe insertion (place mout guard on

the probe (caution : not to place backward !! )

3. Lubricate tip of TEE probe with 2% lidocaine jelly

4. Anteflex the probe slightly before insertion

5. Insert through the midline, with plane facing the tongue

 Inserting the probe
Position the pts in the lateral decubitus position reduce risk of
aspiration

Flex the neck

Always use a bite block

A disposable sheath will protect the probe and pts

Direct the probe centrally towards the back of the pharynx

Advance the probe to appr 30-40 cm, look at the monitor

 Tips and Tricks for smooth and safe
probe insertion
1. Make a good connection to the patient by good communication
earn patients trust.

2. For operator : Be calm and relax, but cautious. Your anxiety is

contagious to patient. Reassurance is the best sedat

3. Explain the detailed procedure, step by step

4. Ask the patient to swallow voluntarily, while operator push slowly.

Never rush, never force, never make sudden push.

5. If any restriction during insertion stop ! Dont push the probe

How to insert the probe
 Side Effect of Topical Anesthesia

1. Risk of methemoglobinemia

2. Sign & symptoms : dyspnea, nausea, tachycardia, cyanosis, drop in

O2 saturation

3. Arterial blood characteristic : Chocolate brown

4. Treatment

1. O2 administration

2. Antidote : methylene blue solution 1% (10 mg/ml) 1-2 mg/kg

slowly IV administration over 5 mins then flush with saline
 Anesthesia Agents
Onset &
Type Name Dose Precaution Antidote
duration
benzodiazepine midazolam Quick onset 1 2 mg Delirium, Flumazenil (0.2
Short duration confusion mg, next + 0.2
(in elderly) mg/min

opioids fentanyl Quick onset 50 mcg Respiratory Naloxon (0.1

depression, mg, next + 0.1
vomiting, mg/min)
nausea
sedative hypnotic propofol rapid sedation 40 200 mg none
and recovery (75 90 mg)

Local anesthesia Benzocaine, sprays methemoglobi Methylene

Lidocaine nemia blue 1% (1-
2mg/kgBB, IV)
Swallowing Process
TEE related injury

Hilberath JN et al. JASE 2010;23:1115-27

Probe Malposition
Probe manipulation
 Performing TEE
Safety Tips and Tricks

1. Know exactly what you are looking for.

2. Work systematically, start with very important information needed from

TEE.

3. Evaluate previous echo result (TTE / TEE), to get a full picture, and avoid
missing information needed

4. Correlate with TTE, and then go back and this time take another look at
the history

5. Record everything (CDs are cheap, errors are expensive)

6. Dont let the pts drive for 24 hours after sedation