Transesophageal Echocardiography (TEE) for Resuscitation 2019-07-27T21:44:32+00:00

Transesophageal Echocardiography (TEE) for Resuscitation

Disclaimer: TEE examinations carry risks of complications and should only be performed in the appropriate clinical situation by a trained provider. This section does not provide a comprehensive overview of TEE but highlights the most useful views for resuscitation and diagnostic assistance in critically ill patients. It should be noted that TEE is complimentary to TTE, and for certain clinical questions TTE may be preferable (RV assessment, pericardium, cardiac output).

Common Indications

  • Shock assessment in patients with inadequate transthoracic windows
  • Cardiac arrest
  • Extracorporeal life support procedural guidance
  • Suspected acute aortic disease and shock/cardiac arrest

Absolute Contraindications*

  • Esophageal tumour/stricture/diverticulum
  • Esophageal/viscous perforation
  • Active UGIB

*Resuscitative TEE is not recommended in not intubated patients due to increased risk of complications

Relative Contraindications

  • Recent UGIB
  • Varices
  • Coagulopathy/thrombocytopenia
  • Hx of radiation to neck/mediastinum
  • Hx of GI surgery
  • Hx dysphagia
  • Barrett’s esophagus
  • Active esophagitis, peptic ulcer disease
  • Restricted neck mobility
  • Symptomatic hiatal hernia

J Am Soc Echocardiogr. 2013;26:921-64

  1. Appropriately sedate patient; consider neuromuscular blockade.
  2. Insert bite block add gel/lubricant.
  3. Position patient’s head midline and apply jaw thrust.
  4. Ensure probe wheels are not locked, gently insert probe midline with flat surface facing floor of mouth, consider slight ante-flexion if resistance felt.
  5. At ~15cm depth there may be slight resistance followed by release and passage of probe past hypopharynx and into upper esophagus. Do not use excessive force during insertion. Consider video or direct laryngoscopy for guided insertion if initial attempt unsuccessful.
  • Rotation – probe can be rotated clockwise/counterclockwise in its long axis. Use both hands simultaneously, one at the patient’s mouth and the other on the probe handle.
  • Big wheel: -clockwise -> anteflexion

-counterclockwise -> retroflexion

  • Small wheel:
    1. Clockwise -> rightward flexion
    2. counterclockwise -> leftward flexion
  • Omniplane (0-180°):
    1. Button furthest from probe tip -> increases angle
    2. Button closest to probe tip -> decreases angle

*do not advance/withdraw probe when ante/retroflexed or if wheel(s) locked to minimize risk of luminal injury

Optimization: advance/withdraw probe to use LA as acoustic window, consider ante/retroflexion to align with long axis of LV/RV

Utility: LV/RV size and function, assess for MR and TR, easy to obtain view to use as starting point for other views

*use ME4C view as a starting point from which to obtain other views and to reorient oneself if bearings lost

 Sample ImageHow To Obtain from ME4COptimizationClinical Utility
Midesophageal 2 ChamberChange omniplane to 90°Rotate left/right to maximize LV cavityLV function with focus on anterior and inferior wall, assess for MR
Midesophageal Long AxisChange omniplane to 120°Advance/withdraw probe to center LVOT/AoV or MVLV function, assess for MR and AR, may be used in cardiac arrest to guide compressions so as to avoid compression of LVOT
BicavalChange omniplane to 90°
Rotate probe clockwise to visualize RA in center of screen
Advance/withdraw probe to center SVC or IVC, rotate to avoid cylinder effect on SVCFluid responsiveness likely if SVC collapsibility in paralyzed pts 36%*

Caveat: patients must be synchronous with ventilator with no spontaneous efforts, in regular cardiac rhythm, and with tidal volume ~8ml/kg

(max diameter on expiration-minimum diameter on inspiration)/(max diameter on expiration)

Procedural guidance to confirm appropriate Placement of wire/cannulae in SVC/IVC
Midesophageal Ascending AortaWithdraw probe past visualization of AoVChange omniplane to 90° for long axis viewAortic dissection/aneurysm
Midesophageal Arch and Descending AortaRotate probe completely 180° so that probe is facing posteriorly (towards spine/descending thoracic aorta)Change omniplane to 90° for long axis view, advance/withdraw probe to visualize entire aortaAortic dissection/aneurysm
Transgastric Short AxisAdvance probe into stomach (past LA window and coronary sinus) and once rugae or liver visualized anteflex probeRotate probe to center LV cavity on screen, considerable anteflexion typically neededLV/RV function, assess interventricular septal kinetics

J Am Soc Echocardiogr. 2013;26:921-64

*Intensive Care Medicine. 2004,30(9), 1734-1739

SVC Collapsibility Calculator

Max diameter on expiration
Minimum diameter on inspiration
SVC Collapsibility