TEE (Transesophageal Echocardiogram)

Anesthesia Implications

Position: Supine, Left Lateral, HOB 20-30 degrees
Time: 5-30 min (very short)
Blood Loss: Zero
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: No

TEE contraindications – History of Esophageal varices, current/past throat radiation, esophageal narrowing/stricture

Possible complications – Laryngeal spasm while inserting probe (keep emergency airway kit close), submucosal or esophagus trauma/hematoma, teeth damage. TEE patients will typically have low cardiac output so they are at risk for severe bradycardia and hypotension (keep emergency medication close).

Induction – (Similar to EGD) Start propofol. When patient is sufficiently sedated, let the cardiologist know that the patient is ready for the TEE probe.
As the surgeon advances the probe, a jaw lift may aid in the insertion if the patient is too sedated to swallow. Continue infusing/pushing propofol as needed, per patient comfort and respiratory/hemodynamic status.

Typical Medication Lineup – Versed 1-2mg preoperatively, Robinul (0.1mg to decrease secretions), Fentanyl (25mcg to decrease sympathetic response to probe insertion), lidocaine IV bolus, propofol drip or bolus as needed. Consider low dose ketamine or precedex for patients needing more sedation without decreasing respiratory drive.

Off-site – In most cases, these procedures will be done away from the OR. Make sure to pack emergency equipment and medications to secure the airway and handle swings in hemodynamics.

Low Ejection Fraction (EF) – If patient has a particularly low EF ( less than 30), gargling numbing spray (Hurricane Spray) or viscus lidocaine can decrease coughing and decrease the need for medications that effect hemodynamics and respirations.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.

TEEs are typically performed in a preoperative, outpatient or inpatient setting to assess the heart with ultrasound from the position of the esophagus. By using an esophageal probe (similar to an EGD) the cardiologist can easily examine the heart structures that lie directly beside the esophagus.

Indications for TEEs – Assessment of the left atrium for a thrombus when the patient has atrial fibrillation. TEEs are also used for the assessment of heart conditions and diseases, such as: Endocarditis, valve disease, cardiomyopathy, pericardial disease, congenital heart disease, and myocardial or coronary heart disease.