Koenig – Transesophageal Echocardiography in the Intensive Care Unit

Seth J Koenig, MD, Professor, Dept of Medicine and Cardiovascular and Thoracic Surgery; Professor of Medicine, Donald and Barbara Zucker SOM at Hofstra/Northwell; Director, Acute Lung Injury Center, Northwell Health; and Director, MICU at the Long Island Jewish Medical Center, presents on “Transesophageal Echocardiography in the Intensive Care Unit”.

Lecture Summary: TEE in the ICU – Seth Koenig

Summary by Dr. Keegan Tupchong

TEE in the ICU

• not dangerous
• not hard
• can be mastered by non-cardiologists
• data show that it helps clinical decision-making

Reasons to learn TEE

• Anyone who is critically ill probably deserves POCUS
• TEE is used for all ECMO cannulations at Long Island Jewish Medical Center
• You will be left behind if you don’t start learning TEE in fellowship
  • the same paradigm used to exist for learning general POCUS as well as critical care TTE, and now everyone has POCUS in their ICUs
• Taking good care of a patient means that at least you must know what is wrong
  • while it does not replace clinical skills, TEE as an adjunct can give you the data needed to become a better clinician
• TEE is much less dangerous and complicated than many other procedures required by ABIM:
  • airway management
  • CVCs, A-lines, PACs
  • ventilator management
• There may not be an RCT showing improved outcomes with TEE but …
  • this has yet to be shown for ventilators, CT scans
  • “we hold these truths to be self-evident” and assume that they benefit patients
• Categorizing the shock state is essential
  • “if you understand the shock state then you know how to treat the shock state”
  • diagnosis of life-threatening diseases saves lives
  • hemodynamic profiles change constantly

TEE image acquisition:

• There are different types of gross movements
• vertical (advance/withdraw the probe)
• rotational (turning the probe/beam plane)
• anteroflexion/retroflexion
• lateral flexion
• multi beam
• Beam path is the opposite of TTE (from inside the chest pointed outwards)

Ten Reasons for Performing Hemodynamic Monitoring Using TEE (Vignon, et al, ICM, 2017)

1. TEE provides a unique window to the heart and great vessels (e.g. dissection)
2. TEE provides unparalleled information on the mechanism of circulatory failure (e.g. saddle PE, too unstable to go to CT)
3. TEE allows reproducible and sequential hemodynamic assessments
4. (e.g. slightly large RV but normal SV (normal HR, VTI) may point towards vasodilatory rather than obstructive shock (with old RV dysfunction))
5. TEE predicts fluid responsiveness (better than any other cardiac output monitoring paradigm)
6. TEE is best suited to quantitatively assess cardiac function (e.g. degree of severity of mitral regurgitation)
7. TEE is key to identifying RV dysfunction at the origin of low flow states (e.g. large ASD)
8. TEE is the only possibility to monitor hemodynamic status in the context of the use of ECMO (e.g. cannula placement)
9. TEE is quicker and easier to initiate than other monitoring modalities, and less operator dependent than TTE
10. Miniaturized TEE probes allow prolonged hemodynamic monitoring
11. TEE potentially improves ICU performance

Complications

• Risk of death = 0.0098% (cardiology TEE)
• Several large studies combined show ~1 death in 30,000 patients
• All complications of any type = 2.8% (lower than for central lines, transbronchial biopsies, etc…)
  • hypoxemia
  • hypo/hypertension
  • dislodged NGT
  • minor upper airway injury

Diagnostic Accuracy of and Therapeutic Impact of TTE and TEE in Mechanically Ventilated Patients in the ICU (Vignon, et al, ICM, 2017)

• no deaths from TEE
• when TTE could not solve a clinical problem, TEE was performed, and the majority were solved with TEE
• Only 4 views are likely needed
  • mid-esophageal 4 chamber (RV and LV size and function, mitral valve)
  • mid-esophageal long axis (aortic valve)
  • bicaval (preload responsiveness)
  • transgastric short axis (RV and LV size and function)

Impact of Critical Care TEE in Medical-Surgical ICU Patients: Characteristics and Results from 274 Consecutive Examinations (Arntfield, et al, J ICM, 2018 )

• TEE aids clinicians in decision-making (e.g. dissection)
• Focused TEE by Emergency Physicians is Feasible and Clinically Influential
• Takes 30-35 TEE studies to achieve competence for non-cardiologists

Critical Care Fellow Training and Utilization at Long Island Jewish:

• 3 modules, ~4 TEE views in each
• each performs 10 exams on a simulator
• most can master the TEE exam in real patients after 10-20 exams (as opposed to 30-35, above)

Feasibility, Safety, and Utility of Critical Care TEE Performed by Pulmonary and Critical Care Fellows in the ICU (Garcia, et al, Chest, 2017)

• 129 exams at LIJ by fellows
• 100% success in insertion and image acquisition
• TEE led to a change in clinical management
• 35% therapeutic change, 65% therapeutic no change (a negative exam still gives you lots of information)

References

Mayo, Paul H., Mangala Narasimhan, and Seth Koenig. “Critical care transesophageal echocardiography.” Chest 148.5 (2015): 1323-1332. https://www.sciencedirect.com/science/article/pii/S0012369215502444

Jaidka, Atul, et al. “Better with Ultrasound: Transesophageal Echocardiography.” Chest (2018). https://www.sciencedirect.com/science/article/pii/S0012369218325637

Garcia, Yunuen Aguilera, et al. “Feasibility, safety, and utility of advanced critical care transesophageal echocardiography performed by pulmonary/critical care fellows in a medical ICU.” Chest 152.4 (2017): 736-741. https://www.sciencedirect.com/science/article/pii/S0012369217312059

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