DK2985_C000 1..28 - AlSharqia Echo Club

Equipment, Complications, Infection Control, and Safety 151A LARYNXTEE PROBEETTFigure 7.11 TEE probe insertion using the fiberoptic laryngoscope.Resistance will be encountered when the probe is notdirected in the midline position (ETT, endotracheal tube).anesthesia or conscious sedation in a cooperative patient.Under general anesthesia, blind intubation is commonlydone using the second and third fingers as a guide or topull up the mandible to assist TEE insertion while theprobe is kept central to the tongue (Fig. 7.9). Unexpecteddifficult esophageal intubation may occur (Fig. 7.10) andbenefit from placement under direct laryngoscopy toreduce the risk of lesion associated with numerous blindattempts (Fig. 7.11). Occasionally, the endotracheal tubecuff may have to be deflated to facilitate insertion.Under conscious sedation, adequate local anesthesiacombined with light sedation and reassurance can be sufficientfor the patient to tolerate probe insertion and TEEexamination. Placed in the left lateral decubitus or sittingposition, the patient is asked to try to swallow the probe.The deglutition maneuver closes the vocal cords and thelarynx moves forward to the posterior aspect of thetongue while the cricoid muscle relaxes. Local or systemicanalgesia greatly contributes to patient tolerance by reducingretching and suppressing the gag reflex.The probe insertion should be smooth and not meetundue resistance. Forced insertion can cause vocal cordtrauma or esophageal wall laceration. Mobilization ofthe probe should never be performed with the probe in alocked and flexed position (Fig. 7.8). During insertion,the ultrasound system display can be monitored toconfirm the correct insertion of the TEE probe and todetect rapidly inadvertant tracheal intubation with associatedimage loss or appearance of tracheal rings (Fig. 7.12)(15,16). Under general anesthesia, this could be missedunless ventilation pressure modification is recognized. Inthe awake and sedated patient, tracheal intubation maybe suspected in the event of stridor, coughing, wheezing,and desaturation while the ultrasound system displayreveals tracheal rings or poor images due to interferencefrom air in the trachea. In heavily sedated patients, trachealplacement can sometimes only be suspected by the presenceof desaturation. The insertion and removal of theTEE probe can also be associated with displacement ofthe endotracheal tube.IX.COMPLICATIONS OF TEEAccording to numerous studies, total complications,including minor and major events, vary between 0.6%and 3.5% (17–19). These results compare favorably withthose encountered for gastrointestinal (GI) endoscopy.The TEE examination carried out in emergency settingshas a higher complication rate of up to 12.6%. Severalfactors contribute to this situation, including the emergentnature of the TEE need, the hemodynamic status of thepatient, the alteration of consciousness and the risk ofaspiration from a full stomach. The TEE related complicationsare illustrated in Fig. 7.13.Failure to introduce the probe correctly into the oesophagusoccurs in an estimated 1–2% of attempted procedures.Most of the time, it is attributed to the lack ofpatient collaboration or tolerance, and to the operator’sinexperience. In the setting of multiple unsuccessfulattempts, it is sometimes beneficial to reschedule theexam and plan it under general anesthesia and direct laryngoscopicvisualization.(A)(B)AORTIC ARCHRPA(PA CATHETER IN SITU)Figure 7.12 Transverse plane transtracheal image and diagram of aortic arch and right pulmonary artery. Distal structures were notclearly visualised (RPA, right pulmonary artery). [With permission from Sutton (16).]