Rescue TEE

Question 1

Rescue Tool

Answer 1

•role of TEE in critical emergency intraoperative setting is beneficial for establishing diagnosis and directing therapies in 80% of patients
•time-dependent
•goal directed
•looking for treatable causes of sudden cardiac arrest
- MI
- hypovolemia
- dynamic LVOTO
- pericardial effusion / tamponade
- PE
- paradoxical emboli
- acute valvular regurgitation
- intracardiac masses
•TEE > TTE for intrapericardial clots and posterior loculated effusions

Question 2

Pericardial tamponade

Answer 2

•significant compression of heart by accumulating pericardial contents
•effects of fluid accumulation depends on volume and rate of accumulation
•collapsing of chambers — occurs when pericardial pressure&raquo_space; chamber pressure
- compliant atria first then ventricles
- diastole before systole
- right side before left side
•RV diastolic collapse — specific for tamponade
- pericardial pressure&raquo_space; RV pressure
•Atrial compression — less specific but more sensitive for tamponade
- begins in late diastole and continues into ventricular systole
- swinging heart motion
- can occur under normal conditions

Question 3

Pulmonary Embolus

Answer 3

•TEE specificity 95% — if you see a thrombus… it’s probable a PE
•TEE sensitivity 46% — if you don’t see it… still can’t rule out
•Associated signs:
- RV hypokinesis, enlargement
- small LV, flattening of IVS or paradoxical septal motion
- dilated PA, RA
- distended IVC with loss of respiratory variation
- tricuspid regurgitation
- McConnell’s sign — regional WMA sparing RV apex suggests massive PE and poor prognosis

Question 4

Low SVR

Answer 4

• adequate end diastolic area [normal EDD = 3.7 - 5.3 cm]
• hyper dynamic wall thickening
• reduced end systolic area
• SVR = (MAP - CVP) x 80 / CO [normal = 700 - 1600 dynes/s/cm^5]

Low SVR

• EDA normal
• ESA reduced

Hypovolemia

• EDD < 2.5 cm
• EDA < 55 cm^2

Question 5

TEE Safety

Answer 5

•morbidity 0 - 0.5%
•comparable morbidity and mortality results to EGD w/ complication rate of 0.08 - 0.13% and 0.004%
•complications:
- odynophagia 0.1%
- upper GI bleed 0.03%
- perforation 0.01%
- dental injury 0.03%
- ETT malposition 0.03%
- mortality 0%

If you meet resistance … STOP.