PROCEDURE Transesophageal 80 Echocardiography (Assist)

Janice Y. Dawson and Linda Hoke PURPOSE: Transesophageal echocardiography (TEE) offers an alternative approach for obtaining high-quality images of the heart structure that are not well visualized with a conventional transthoracic echocardiography (TTE) approach. A TEE obtains images of the heart from a transducer inside the esophagus. The esophagus lies immediately behind the heart, and with this technology clear images of the heart can be obtained.

PREREQUISITE NURSING structures. These images represent “slices” of the heart KNOWLEDGE in motion. ❖ Three-dimensional (3D) echocardiography provides • Knowledge of cardiovascular anatomy and physiology is added dimensions to the 2D echocardiogram. It pro- necessary. vides detailed anatomical assessment of cardiac pathol- • Knowledge of basic arrhythmia recognition and treatment ogy, chamber volume measurement, and views of heart of life-threatening arrhythmias is needed. valves, enabling a better appreciation of the severity • Advanced cardiac life support (ACLS) knowledge and and mechanisms of valve diseases. skills are needed. ❖ Doppler echocardiography: This assesses the fl ow of • A topical anesthetic is used in the oropharyngeal area; blood through the heart. The signals that represent thus, the patient’ s gag refl ex may be diminished or absent, blood fl ow are displayed as a series of black-and-white putting the patient at risk for aspiration. 4 tracings or color images on the screen. • It is essential to know the institution ’ s conscious sedation • A TEE is considered a safe and relatively noninvasive diag- guidelines. nostic technique. However, severe, even life-threatening • Sedation can put the patient at risk for respiratory complications have been reported.5 depression.9 • General indications for TEE are as follows1,2,4 : • A fi beroptic probe with an ultrasound transducer is inserted ❖ Evaluation of cardiac and aortic structures and function through the mouth into the esophagus just behind the heart with inadequate TTE images or in whom diagnostic (Fig. 80-1). The transducer located at the tip of the probe information is not obtainable by TTE sends high-frequency sound waves toward the heart, ❖ Rule out clot prechemical and/or electrical which returns as echoes. The echoes are converted, by cardioversion computer, into moving images of the heart. The image is ❖ Suspected acute thoracic aortic pathology including displayed on a screen and can be recorded on videotape but not limited to dissection/transection or compact disk (CD), printed on paper, or sent electroni- ❖ Evaluation of valvular (mitral) structure and function cally to a picture-archiving communication system. This to assess appropriateness for, and to assist with plan- test is used to visualize structures of the heart and aorta ning of, an intervention that may not be seen with a standard TTE and to clarify ❖ Diagnosis of infective endocarditis with a high pre test structures that may be otherwise poorly seen. The test may probability (e.g., staphylococcus bacteremia, funge- be performed as an outpatient or inpatient procedure or in mia, prosthetic heart valve, or intracardiac device) 4 the operating room. ❖ Evaluation for cardiovascular source of embolus with • Various modes of echocardiography are used to examine no identifi able noncardiac source the heart, blood vessels, valve function, and blood fl ow. ❖ Intraoperative cardiac monitoring The three techniques include: ❖ Guiding the management of catheter-based intracar- ❖ Motion-mode (M-mode) echocardiography: This is a diac procedures such as septal defect closure or one-dimensional echocardiogram that visualizes time, atrial appendage obliteration and transcatheter valve depth, and intensity. It looks like a tracing instead of a procedures picture of the heart and is used to measure the exact ❖ Prosthetic valve disorders size of the heart chambers. • Contraindications to TEE can be divided into absolute ❖ Two-dimensional (2D) echocardiography: This shows and relative. Gastrointestinal (GI) evaluation and clear- the actual shape and motion of the different heart ance should be considered before the procedure.

698 80 Transesophageal Echocardiography (Assist) 699

Transesophageal Echocardiogram (TEE)

Esophagus

Transesophageal echocardiography (TEE) probe in Heart esophagus Echocardiogram monitor (probe can also be placed in Atrium the stomach)

Ventricle Sound waves create pictures of the heart

Stomach

Figure 80-1 Transesophageal echocardiography (TEE) probe inserted through the mouth and into the esophagus just behind the heart.

• Absolute contraindications are as follows2,5 : EQUIPMENT ❖ Diseases of the throat/esophagus/stomach including, but not limited to, known obstructive esophageal • Transesophageal ultrasound probe disease, obstruction, stenosis, tumors, fi stulae, or varices • Echocardiography machine (compatible with the probe) ❖ Esophageal perforation, laceration • Constant low wall suction with connecting tubing and ❖ A history of esophageal radiation or unresolved esoph- rigid pharyngeal suction tip catheter ageal dilation • Protective mask, goggles, nonsterile gloves, and barrier ❖ Perforated viscus gowns ❖ Dysphagia and odynophagia • Water-soluble lubricant ❖ Active upper GI bleeding • Oxygen, with both nasal prongs and mask available ❖ Patients who ate within 6 to 8 hours of the study, unless • Topical anesthetic such as lidocaine solution with an emergent as in aortic dissection or trauma administration device (i.e., mucosal atomization device), ❖ Unwilling patients viscous lidocaine, or benzocaine spray (as prescribed) ❖ Inability to obtain intravenous access • Premedication for sedation and appropriate reversal agents • Relative contraindications are2,5 : (as prescribed) ❖ Upper GI surgery • Syringes, blunt needles, and labels for medications ❖ Recent upper GI bleed • Antiseptic agents for IV connection cleansing such as ❖ History of radiation to neck and mediastinum alcohol prep pads ❖ Barrett ’ s esophagus • IV insertion kit (if adequate IV access is not in place) ❖ History of dysphagia • IV tubing ❖ Restriction of cervical mobility from severe cervical • One bag (500 mL or 1000 mL) of 0.9% normal saline IV arthritis solution ❖ Esophageal varices • Syringes of proper size for aspirating and fl ushing IV ❖ Coagulopathy, thrombocytopenia access if needed ❖ Active esophagitis • Tongue depressor ❖ Active peptic ulcer disease • Emesis basin ❖ Loose teeth • Flashlight (to assess the oropharyngeal area, especially in • A TEE does not pose a risk for infection. Patients with the case of trauma) prosthetic values do not need antibiotics prescribed before • Disposable bite guard (may use the type with or without the procedure.7 a strap to hold it in place) 700 Unit II Cardiovascular System

• Thermometer • Continuous electrocardiographic monitor PATIENT ASSESSMENT AND • Continuous pulse oximetry monitor and equipment PREPARATION • Continuous capnography monitor and tubing (organiza- tion specifi c) Patient Assessment • Automatic blood pressure machine and cuff (with manual • Verify the correct patient using two identifi ers. Rationale: blood pressure cuff available for backup use) Before performing a procedure, the nurse should ensure • Two pillows, one supporting the neck and one supporting the correct identifi cation of the patient for the intended the back, to maintain the side-lying position procedure. • Bags with respective labels for carrying probe to and from • Assist the physician, advanced practice nurse, or other procedure (institution specifi c) healthcare professional with assessing the patient ’ s medical • ACLS cart, airway equipment, and medications history for absolute and relative contraindications for the Additional equipment, to have available as needed, includes TEE procedure. Rationale: Screening for absolute and the following: relative contraindications for the TEE procedure prevents • Denture cup with patient identifi cation adverse outcomes. • Tonsillar forceps and cotton balls with radiopaque string • Assess the patient ’ s baseline cardiac rhythm. Rationale: attached (institution specifi c) The patient’ s rhythm may have converted if the indica- • Methylene blue, if benzocaine spray is used tion for the procedure was an arrhythmia. Passage of a • Ultrasound gel large-bore tube may cause vagal stimulation and brady • Three-way stopcock and syringes, at least two 10-mL arrhythmias. syringes with normal saline fl ush solution and one 10-mL • Assess the patient ’ s history of medication allergies. Ratio- empty syringe, for the administration of the saline contrast nale: Identifying allergies may avoid an adverse medica- agent if used tion reaction. • Confi rm the patient was NPO for the prescribed length of PATIENT AND FAMILY EDUCATION time. Rationale: NPO status for an appropriate period of time before the procedure allows for gastric emptying and • Assess the patient and family ’ s understanding of the pro- decreases the likelihood of aspiration. cedure and the indication for therapy. Rationale: Informa- • Assess the patient ’ s medication history.1 Rationale: Fre- tion about the procedure increases patient cooperation and quent use of certain medications (e.g., analgesics and anx- decreases patient and family anxiety and apprehension. iolytics) or illicit drugs and alcohol may affect the patient ’ s • Verify that the patient understands the preparation for the response to moderate sedation and the medications. procedure, which includes not having food or nonclear • Confi rm medications the patient has taken within the liquids for at least 6 hours and nothing by mouth (NPO) last 4 hours. Rationale: Recent sedative, analgesic, and for 2 to 3 hours before the procedure as prescribed.4,8 vasoactive medications may affect the patient’ s toler- Before the test, the patient may take daily medications, ance and response to the medications given during the with a sip of water, as prescribed or according to institu- procedure. tion standards. Rationale: Undigested material in the • Assess the patient ’ s height, weight, baseline respiratory, stomach increases the risk for aspiration. Prescribed medi- hemodynamic, and neurological status before anesthetiz- cations may be needed. ing the posterior pharynx and administering any sedative • Explain that the local anesthetic may make the patient ’ s agents. Rationale: Baseline assessment data provide tongue and throat feel swollen and that he or she may feel information to use as a comparison for further assessment unable to swallow. The gag refl ex will be inhibited by the once medications have been administered. local anesthetic and may last approximately 1 hour after • Assess the patient ’ s baseline vital signs, oxygen satura- administration. They may experience gagging or retching tion, and if applicable capnography reading. Rationale: during the numbing process and during the initial passage Close monitoring of vital signs and oxygenation during of the probe. Rationale: The explanation may assist in the procedure and comparison with baseline are essential decreasing patient anxiety during the procedure. to assess the patient’ s tolerance of the procedure. • Explain to the patient he or she will be sedated to decrease • Assess the patient ’ s baseline pain characteristic, site, and anxiety, to increase comfort, and for ease in passing the severity. Rationale: Baseline assessment data provide probe. Rationale: This information may decrease patient information to use as a comparison during and after the and family anxiety. procedure. • Describe to the patient he or she will be monitored closely • Assess the patient ’ s presedation level of consciousness, during and after the procedure. Rationale: The explana- using an organization-approved scoring system (e.g., tion assists in decreasing patient and family anxiety. Modifi ed Aldrete Score).4 Rationale: Using a scoring • Explain to the patient he or she will require transporta- system for conscious sedation may prevent oversedation, tion after the procedure and needs to be accompanied by and establish a baseline for postprocedure comparison. a responsible adult if it is performed in an ambulatory • Assess the patient for medical problems that contraindi- setting. Rationale: Even short acting medications may cate or increase the risk of conscious sedation. Consider not be metabolized for a few hours making it unsafe to using the American Association of Anesthesiologists ’ drive. Physical Status Classifi cation Score per institution policy. 80 Transesophageal Echocardiography (Assist) 701

Rationale: Screening the patient preprocedure may fi nd a • Maintain the prescribed IV infusion during the procedure. history or evidence of diffi cult intubation, sleep apnea, Rationale: IV infusion maintenance ensures the IV is and complications of sedation or anesthesia.4 functioning and available should an emergency arise. • Have the patient remove any dentures or dental prosthe- Patient Preparation ses. Rationale: Dentures may interfere with the safe • Verify that the patient and family understand preproce- passage of the transesophageal probe. dural teaching. Answer questions as they arise, and rein- • Set up the suction system with the connecting tubing and force information as needed. Rationale: Understanding of a rigid pharyngeal suction tip device attached and ready previously taught information is evaluated and reinforced. for use. Check for adequate suction vacuum. Rationale: Patient and family anxiety may be decreased. This setup is necessary for suctioning the patient ’ s oral • Verify that informed consent was obtained, including secretions during the procedure. consent for anesthesia and agitated saline contrast injec- • Prepare the prescribed local anesthetics (e.g., benzocaine, tion, if required. Rationale: Informed consent is necessary viscous lidocaine); sedatives (e.g., midazolam, diazepam); before invasive procedures and the administration of con- analgesics (e.g., fentanyl, morphine sulfate); reversal scious sedation. Informed consent protects the rights of agents (e.g., naloxone, and fl umazenil); medications to the patient and makes a competent decision possible for decrease salivary secretions as needed; and methylene the patient; however, in emergency circumstances, time blue (if benzocaine use is planned).4 Rationale: Sedatives may not allow the form to be signed. and analgesics reduce patient anxiety, promote comfort, • Instruct the patient to void before the procedure. Ratio- facilitate cooperation during the procedure, and decrease nale: Voiding before the procedure minimizes disruption myocardial workload. Reversal agents are required for of the examination. emergencies. Methylene blue is needed to reverse methe- • Perform a preprocedure verifi cation and time out. Ratio- moglobinemia if it occurs with the use of benzocaine.4 nale: Ensures patient safety. Confi rms correct patient, • Have agitated normal saline solution available per orga- procedure, and equipment availability. nization protocol if prescribed for saline contrast echocar- • Initiate or continue electrocardiographic monitoring, apply diography (bubble study). Rationale: The contrast agent an automatic blood pressure cuff (if arterial blood pressure enhances the ability to evaluate cardiac shunt. monitoring is not already in place), and initiate oxygen satu- • Administer supplemental oxygen as prescribed. Ratio- ration monitoring and, if prescribed, capnography. Ratio- nale: Administration of oxygen may be needed to main- nale: These measures allow for close cardiovascular and tain adequate patient oxygenation during the procedure. respiratory monitoring during the procedure. Follow orga- • Have atropine available at the bedside. Rationale: Atro- nizational practice regarding capnography monitoring. pine is necessary if a vagal reaction occurs with the inser- • Ensure the ordered IV access is in place and functional, tion and passage of the transesophageal probe. usually a 20-gauge or larger IV. Rationale: IV access is • Have an ACLS cart, medications, and airway equipment needed to administer premedication and for possible available at the patient’ s side. 4 Rationale: Emergency emergency medications. A 20-gauge or larger IV is needed equipment is necessary to have close by in case an emer- for the injection of contrast if prescribed. gency situation should arise.

Procedure for Transesophageal Echocardiography (Assist) Steps Rationale Special Considerations 1 . HH 2 . PE 3. Assist if needed as the physician, Decreases discomfort caused by If possible, allow the patient to sit up advanced practice nurse, or other passage of the probe. to increase comfort and decrease healthcare professional anxiety or the feeling of choking. anesthetizes the patient ’ s posterior pharynx with the topical agent. 4. Assist the patient to the left- The left-lateral decubitus position Patients may be examined in the lateral decubitus position. Use allows secretions to collect in the supine position if required by pillows to ensure correct dependent areas of the mouth for anatomy or hemodynamic stability alignment of the spine with the ease of suctioning and to prevent or if the patient is endotracheally head and body. aspiration in case the patient intubated.4 vomits. 5. Reassess vital signs, oxygen Closely monitors the patient and saturation, capnography, determines whether there are any neurological status, cardiac changes in the patient ’ s condition. rhythm, respiratory status, and pain before administration of IV medications for moderate sedation. Procedure continues on following page 702 Unit II Cardiovascular System

Procedure for Transesophageal Echocardiography (Assist)—Continued Steps Rationale Special Considerations 6. Administer IV medication for Allows the patient to cooperate in Confi rm the appropriate antagonists moderate sedation as prescribed.4 facilitating passage of the probe are readily available. (Level D * ) during the procedure. Continually assess the patient as he or she may need additional medication throughout the procedure. 7. Assist the physician, advanced Gag and cough refl exes may be practice nurse, or other compromised by topical anesthetics, healthcare professional as needed and the patient may vomit as the with the insertion of the probe. probe is passed, increasing the risk A. Prepare to insert a bite guard The bite guard prevents the patient for aspiration. when directed by the from biting the probe or the fi ngers physician, advanced practice of the physician, advanced practice nurse, or other healthcare nurse, or other healthcare professional. professional and avoids damage to the teeth and mouth. B. Assist the physician, advanced Lubrication of the probe minimizes practice nurse, or other mucosal injury and irritation, and healthcare professional as facilitates the ease of passage of requested with lubrication of the probe. Contact gel transmits the probe and oropharynx and ultrasound signals. applying ultrasound contact gel or viscous lidocaine to the distal end of the probe. C. Ask the patient to slightly Proper head position eases insertion bend his or her head in a of the probe into the esophagus. forward fl ex. D. Alternatively, if needed assist the physician, advanced practice nurse, or other healthcare professional with the jaw-thrust technique if required to guide the probe insertion. E. Encourage the patient to The swallowing maneuver causes the Some physicians, advanced practice simulate swallowing while epiglottis to close the trachea and nurses, and other healthcare the probe is passed if directs the probe into the professionals may not want to draw requested by the physician, esophagus. attention to the throat and will not advanced practice nurse, or ask the patient to swallow, but other healthcare professional. rather will wait for a natural swallow motion to occur and then insert the probe. F. Suction the oral secretions as Removes secretions. This may be Manipulation of the probe may cause needed to ensure patency of needed due to the patient’ s stimulation of secretions. the airway. diminished gag refl ex and the inability of the patient to swallow oral secretions. G. Provide the patient with May decrease patient anxiety and Some patients may be able to tolerate reassurance and promote patient cooperation. the procedure without analgesia or encouragement to keep the anesthesia when encouragement is bite guard in place, maintain provided.4 the required position, hold still without attempts to speak, and focus on his or her breathing pattern.

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommen dations. 80 Transesophageal Echocardiography (Assist) 703

Procedure for Transesophageal Echocardiography (Assist)—Continued Steps Rationale Special Considerations 8. Provide the physician, advanced Keeps the physician, advanced practice practice nurse, or other nurse, or other healthcare healthcare professional with professional informed of the updates of the patient status patient ’ s condition and possible need during the TEE procedure. for additional sedation or analgesics. 9. Assist with the administration of The administration of saline contrast Assist with instructing the patient to the saline contrast agent as enhances the view of the cardiac perform the valsalva maneuver, prescribed and per institutional structures and function. sniffi ng, or coughing to enhance standards.4,6 right-to-left shunting images, if requested by the physician, advanced practice nurse, or other healthcare professional.6 10. Assist if needed with the removal Provides assistance. Anesthetics may be less effective at of the probe. the end of the procedure, increasing the gag and cough refl exes, thus increasing the patient ’ s risk of vomiting as the probe is removed. Using a rigid pharyngeal suction tip catheter, suction as necessary as the tube is removed to prevent aspiration. 11. Place the probe in an appropriate Reduces the transmission of receptacle for cleaning. microorganisms and prepares the equipment for sterilization. 12. Continue assessment and Ensures patient safety. Keep the patient on the left side with monitoring until the patient his or her head slightly elevated returns to baseline as prescribed; until the gag, swallow, and cough follow institutional standards. refl exes are intact. 13. Discard used supplies in Removes and safely discards used appropriate receptacles. supplies using standard precautions. 14. HH

Expected Outcomes Unexpected Outcomes • Clear visualization of cardiac structures and function • Esophageal or gastric perforation • Immediate preliminary diagnosis • Esophageal, oropharyngeal, or gastric injury or • Note: Negative study results are helpful in excluding lacerations cardiac sources of compromise • Oropharyngeal hematoma • Patent airway • Vasovagal hypotension from esophageal manipulation • Acceptable level of comfort with no adverse reactions • Substernal chest pain to sedation or analgesia • Temporary dysphagia • Aspiration • Respiratory depression • Hematoma in the oropharynx • Unresolved hypotension or hypertension • Arrhythmias, bradycardia, or tachycardia • Laryngospasm • Bronchospasm • Change in neurological status • Air embolism in patients with right-to-left shunt with use of saline contrast • Heart failure • Pain • Methemoglobinemia Procedure continues on following page 704 Unit II Cardiovascular System

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Assess and monitor Changes in vital signs; heart rhythm; Changes in the following: cardiovascular, respiratory, and capnography values; oxygenation; • Neurological status neurological status at a minimum and neurological, respiratory, and • Oxygenation of 5-minute intervals during cardiovascular status may indicate • Capnography the procedure and 15-minute complications related to the • Heart rate and rhythm intervals after the TEE procedure, procedure. • Blood pressure until the patient ’ s condition returns • Respirations to baseline, the prescribed • Cardiovascular status parameters (e.g., vital signs within 10% of baseline),4 and as required by institutional standards. 2. Maintain IV access and infusions Maintaining IV access and infusions as prescribed during and after the ensures IV patency in case procedure. emergency medications are needed. 3. Monitor the patient ’ s sedation Determines the patient ’ s response to • Sedation score outside of score using a tool (i.e., Modifi ed IV moderate sedation and the need prescribed parameters Aldrete Score) 4 during and after for additional sedation. • Worsening sedation score after the the procedure following discontinuation of sedation institutional standards. 4. Assess pain at a minimum of May indicate a complication of the • New onset of pain 5-minute intervals during and procedure or identify the need for • Unresolved discomfort not 15-minute intervals after the pain interventions. relieved after the probe is removed TEE procedure until the patient ’ s Mild throat discomfort is common as • Unusual throat discomfort condition returns to baseline. the topical anesthetic wears off. Administer analgesia as prescribed. 5. Monitor for signs and symptoms Identifi es complications. • Dysphagia of esophageal trauma or • Odynophagia perforation.2,3,5 • Mackler ’ s triad: vomiting, pain, and subcutaneous emphysema • Fever • Agitation • Tachycardia • Hypotension • Chest pain • Respiratory distress • Tachypnea • Dyspnea • Pneumothorax • Pleural effusions 80 Transesophageal Echocardiography (Assist) 705

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 6. Monitor for intraprocedure Determines the patient ’ s response to • Patient becomes agitated and is complications or reasons to the procedure and identifi es unable to cooperate with the terminate the TEE early.4 complications. procedure • Change in neurological status • Dental or oropharyngeal trauma • Apnea • Hypoxemia • Hypercapnia • New arrhythmia • New hypotension or hypertension • Perforation or subcutaneous emphysema • GI or other bleeding • Chest pain • Benzocaine-induced methemoglobinemia 7. Monitor a patient who received Severe methemoglobinemia is life • Dyspnea benzocaine for symptoms of threatening. • Nausea methemoglobinemia. Prepare to • Tachycardia treat methemoglobinemia with • Cyanosis supplemental oxygen and • Decreased pulse oximetry levels methylene blue solution given by slow IV administration as prescribed.4 8. Assess the patient for the return The topical anesthesia decreases the • Prolonged absence of gag, of normal pharyngeal function. If gag, swallow, and cough refl exes swallowing, or cough refl exes the patient is not upright, keep and increases the patient ’ s risk of the patient on his or her left side aspiration. with the head of the bed elevated until the gag, swallow, and cough refl exes are intact. 9. Offer clear liquids and gradually Topical anesthesia decreases the gag • Nausea progress to solid food after return refl ex and increases the risk for • Vomiting of pharyngeal function as aspiration. • Stomach discomfort prescribed. • Increase in odynophagia or dysphagia after 24 hours, may possibly indicate soft tissue or esophageal injury.4 10. Ask the patient to repeat his or Having patients repeat the • Patient unable to understand her understanding of the postprocedure instructions confi rms postprocedure instructions postprocedure instructions. their understanding of what they should and should not do. Procedure continues on following page 706 Unit II Cardiovascular System

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 11. Ensure the safety of the This information is provided to ambulatory patient. Ensure vital patients who are being discharged. signs have returned to 10% of baseline before ambulation.4 Have a family member or friend explain postprocedure education and sign appropriate documents as needed. Advise the patient to refrain from important decisions and driving while the effects anesthetic remain (i.e., for the remainder of the day). Provide the patient with a copy of the written discharge instructions, per institutional standards. Counsel the patient to call the physician, advanced practice nurse, or other healthcare professional if odynophagia or dysphagia persists for 24 hours.4 Ensure the patient is accompanied by a responsible adult.

Documentation Documentation should include the following: • Date and time of procedure • Vital signs, pulse oximetry, capnography, • Initial patient assessment neurological status, respiratory status, and pain • Patient and family education evaluation immediately before sedation, and during • Preprocedure verifi cations and timeout and after the procedure • Completion of informed consent form • Establishment and assessment of IV patency

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .