It deals with TEE probe insertion techniques in both awake and sedated patients. it also deals with various TEE probe related complications while inserting probe and also while handling.

1. TEE PROBE INSERTION
&
COMPLICATIONS
KP Gourav,
Senior Resident,
PGIMER, Chandigarh

2. • TEE is considered a safe and relatively non-invasive diagnostic
technique when performed in
• appropriately selected patients
• with proper technique,
• severe, life-threatening complications can occur
• Echocardiographers should be familiar with potential complications of
TEE to allow risk-benefit analysis on individual basis

3. TEE can be done under
1. General anesthesia
2. Awake patient with mild to moderate sedation

4. Preoperative Assessment
Absolute and relative Contraindications
Airway Examination
Suitability for moderate sedation
Last food and drink intake
Written consent
Prepare kit for emergency intubation
Connect and test all TEE probe functions

5. Absolute contraindications
Perforated viscus
Esophageal stricture
Esophageal tumor
Esophageal perforation, laceration
Esophageal diverticulum
Active upper GI bleed
Full stomach
Unrepaired TEF
J Am Soc Echocardiogr 2010;23(11):1115-27.

6. Relative contraindications (2013 guidelines)
 History of radiation to neck & mediastinum
 History of GI surgery
 Recent upper GI bleed
 Barrett’s esophagus
 History of dysphagia
 Restriction of neck mobility
 Symptomatic hiatal hernia
 Esophageal varices
 Coagulopathy, thrombocytopenia
 Active esophagitis
 Active peptic ulcer disease
J Am Soc Echocardiogr 2010;23(11):1115-27.

7. Probe Insertion Technique

8. Under
Anesthesia
Adequate NMB/Sedation
Supine/Head End
Suction of gastric air/contents
Bite Block+/-
Jelly
TEE probe placed – midline; slight anteflexion of probe ;
jaw thrust; Reverse cricoid maneuver
Resistance - Mild retroflexion
Resistance – use fingers to guide the probe into the
posterior fossa
Resistance – use laryngoscope

9. Awake
left lateral decubitus position
Echocardiographer stands left-hand side of stretcher facing
the patient
Topical Anesthesia
bite block
TEE probe placed – midline ; slight anteflexion ; back of the
pharynx
asked to swallow
probe is advanced in neutral position before
conscious sedation
fingers can guide the probe into the posterior fossa
IV line, oxygen, suction
Lidocaine hydrochloride spray for topical anesthesia over
pharynx and tongue
ECG must be monitored throughout

10. Complications related to
TEE probe

14. AP radiograph taken after TEE demonstrating
a foreign body (partial dentures) lodged in the pharynx
J Am Soc Echocardiogr 2009;22:754.e1-2
Thorough preprocedural assessment of
the oral cavity is required

15. Majority are minor and self limiting; some cause significant morbidity

16. Mechanisms of TEE
Associated Injury

17. Improper Probe Placement
If probe is not centered in the posterior pharynx and placed laterally into pyriform fossa, parapharyngeal area is most prone for perforation

18. If placed laterally into the pyriform fossa
the probe may bend or ‘‘buckle’’
Manipulation or rapid removal of probe
- gastroesophageal laceration.

19. • Reported three cases (0.03%) of TEE-associated perforation: one hypopharyngeal
and two cervical esophageal.
• The authors noted that each case was associated with
i. difficult probe placement and
ii. advanced patient age (>75 years).
J Am Soc Echocardiogr 2005;18:925-9.

20. Hypopharynx perforation by a transesophageal echocardiography probe.
Anesthesiology 1995;82:581-3

21. Manipulation of Probe While Locked in
Extreme Anteflexion
Transgastric/deep transgastric views Significant anteflexion of TEE probe tip at GE junction may put
considerable tension on the tissues, causing mucosal disruption or
Mallory-Weiss tears.

22. manipulation of probe within gastrum resulted in
splenic laceration , possibly secondary to torsion of the splenic
hilum indirectly through the gastrosplenic ligament.
J Cardiothorac Vasc Anesth 1998;12:314-6
Laceration and perforation of the gastric cardia and
lesser curvature from transgastric or deep
transgastric probe manipulation
J Cardiothorac Vasc Anesth 2005;19:141-5.

23. Pressure-Related Injury
tissue injury or necrosis secondary to
pressure at the mucosal-probe interface,
especially if the probe is retained for long
periods in a flexed or locked position
Case – TVR
tongue necrosis and formation of a permanent cleft
associated with TEE probe position in a prolonged cardiac
operation.
Anesthesiology
2006;105:635.
(540min)

24. Thermal Injury
created by the piezoelectric crystal vibration within the probe tip or by direct
absorption of ultrasound energy
• Although the risk is minimal, measures can be taken to limit the risk
• probe tip - unlocked, unflexed position when not in use
• minimal gain and acoustic power necessary to obtain adequate images.
• Safety mechanism - most probes are fitted with a thermistor to sense temperature
and automatically shut down if temp.. (42C–44C) is reached.

25. Chemical Injury
aldehyde and nonaldehyde sterilization solutions
has decreased endoscopy related infection rates
but carries the risk for chemical burns in case of
insufficient water rinse
Anesth Analg 2003;97:1260-1
excessive soaking or inadequate rinsing of TEE probes, defects in the probe causing a retention of solution may
result in residual OPA solution Causing chemical burns
lip and tongue appeared Ulcerated
NP examination revealed burns along the right tonsillar pillar, the
right side of the epiglottis, and the right arytenoid region ulceration
below the upper esophageal sphincter.
small gastric ulcer at the greater curvature

26. Infectious Complications

27. Can Happen Late?

28. Role Of Anticoagulation On
Probe Insertion
CAN J ANAESTH 1998 / 45:12 / pp 1196-1199
Undergoing CABG.
TEE probe was inserted once fully heparinized
for CPB and echo was performed.
Immediately after removal of probe,
1.2 L of bright red blood drained from the
orogastric tube.
evidence of a mucosal tear near the
gastroesophageal junction, as well as multiple
erosions noted within the esophagus.

29. Cardiovascular Complications
• Series of 341 obese patients and 323 control patients undergoing TEE, there
was one case of atrial fibrillation in the obese group and one case of
supraventricular tachycardia in the control group associated with the
procedure.
JAmSoc Echocardiogr 2002;15:1396-400.
• Another study of 10,419 patients, found three cases of nonsustained
ventricular tachycardia, three cases of transient atrial fibrillation, and one
case of third-degree atrioventricular block.
Circulation 1991;83:817-21
Release of adrenergic hormones, possible hypoxia and hypercarbia due to sedation could act as a trigger for arrhythmias

31. Respiratory complications with TEE
• respiratory compromise primarily occurs in the non-operative setting includes
• hypoxia,
• unplanned need for endotracheal intubation (secondary to oversedation or aspiration),
• accidental tracheal intubation with the probe
• bronchospasm, and laryngospasm.
• Intraoperative TEE–related endotracheal tube malposition was noted in 0.03% of
cases and can lead to catastrophic outcomes.
Anesth Analg 2001;92:1126-30

32. Safety of TEE in Pediatric Patients
• Until 1989, TEE in paediatric population was limited
• Today, smaller size diameter probes are available - infants & neonates
Am J Cardiol 1993;72:491-2
• smaller size patients - probe insertion may be complicated by compression or
obstruction of the airway or mediastinal structures
• double aortic arch, interrupted aortic arch, or TAPVC may increase the risk for
complications secondary to compression by the TEE probe.

33. • inadvertent dislodgment of ETT or advancement of the tube into the
mainstem bronchus during TEE probe placement or advancement.
J Am Soc Echocardiogr 1999;12:527-32
• Hemodynamic compromise during TEE - 0.07% in 272 pediatric patients
Chest 1999;116:1247-50
• hypotension and ↑peak inspiratory pressures noted with transgastric views,
likely because of anteflexion of the probe against the diaphragm
Anesth Analg 2001;93:594-7

34. TEE Safe in pediatric patients ?
• Andropoulos et al - unable to detect any hemodynamic changes attributable to
TEE in patients weighing 2 to 5 kg
J Cardiothorac Vasc Anesth 2000;14:133-5.
• TEE in pediatric patients appears to be relatively safe

35. Echocardiographic Alternatives To TEE
patients with relative or absolute CI or in unsuccessful TEE probe placement
1. TTE
2. During open-heart surgery - epicardial echocardiography
3. intracardiac echocardiography

38. How to prevent complications?
• Proper preoperative evaluation (CI, AIRWAY etc)
• Generous lubrication - decrease friction
• bite block - keep the probe midline & prevent dental injury/probe itself.
• Never insert/manipulate Probe in locked position
• Depending on patient anatomy, either head flexion/ extension with jaw thrust can
potentially alleviate probe placement into the esophagus.
• Avoid Forceful placement or removal of the TEE probe – if - laryngoscope
• Continued resistance to placement or advancement of the probe, alternative
imaging

39. Summary
TEE looks to be safe and relatively non-invasive diagnostic technique
However, severe and even life-threatening complications can occur
Awareness of possible complications, proper preoperative
evaluation of patients and use of proper technique for probe
insertion can prevent complications

40. THANK YOU