TEE in the ED—What are its Complications?
ABSTRACT & COMMENTARY
Source: Gendreau MA, et al. Complications of transesophageal echocardiography in the ED. Am J Emerg Med 1999;17:248-251.
Gendreau and colleagues, in a retrospective review of 184 consecutive transesophageal echocardiography (TEE) procedures performed in an urban level I trauma center and tertiary care hospital ED, sought to determine the complication rate and high-risk patient subsets in ED patients undergoing this procedure. Prior to chart review, definitions for major and minor complications were established. Forty patients were excluded since TEE was performed outside of the ED; two others were excluded due to inadequate chart documentation. Of the remaining 142 patients, 88 were victims of trauma and underwent TEE to rule out thoracic aortic injury, 53 underwent TEE to rule out aortic dissection, and one patient underwent TEE to rule out prosthetic aortic valve thrombosis. Eighteen (12.6%) patients experienced complications of ED TEE— eight (5.6%) were major and 10 (7%) were minor complications. (See Table.) Patient variables (age, gender, use of sedation, hemodynamics, oxygen saturation, hematocrit, and serum bicarbonate) failed to yield subsets predictive of complications. The authors conclude that, compared to literature reporting a complication rate of 0-5% for TEE performed in the non-ED setting,1-2 TEE performed in the ED carries a higher complication rate, and that no pre-procedural parameters are predictive of complications.
Table-Complications of TEE in the ED | ||
Trauma (n = 88) |
Medical (n = 54) |
|
| Major | ||
| Death | 0 |
1 |
| Respiratory insufficiency/failure | 4 |
3 |
| Minor | ||
| Transient hypotension | 1 |
2 |
| Transient Minor dysrhythmia | 1 |
0 |
| Transient Emesis without aspiration | 4 |
0 |
| Transient Agitation | 1 |
2 |
Comment by Frederic H. Kauffman, MD, FACEP
As with all diagnostic techniques dependent upon operator expertise, as more experience is gained with TEE in the ED setting, the procedure will yield increasingly greater degrees of accurate information with lesser "clinical cost" to the patient. One must always be cautious, however, in evaluating preliminary reports touting the safety and efficacy of new clinical tools. The authors, appropriately, have raised a cautionary flag regarding the use of TEE in the ED setting.
There are several explanations for the high ED TEE complication rate seen in this study. First, data collection began eight years ago. TEE efficacy and safety have improved since its expanded use began in the early 1980s, and certainly during the past decade. Second, not all prior studies evaluating the role of TEE looked at complication rate as a primary study end point. A commonly referenced article by Smith and colleagues found TEE to be accurate and safe in the evaluation of aortic rupture in trauma patients.1 There were no reported complications of the procedure, but eight patients were excluded from evaluation due to inadequate sedation. Such patients would have been considered by Gendreau and colleagues to have experienced complications of TEE. Third, it makes intuitive sense that nearly any major procedure performed in the ED would carry a greater complication rate compared to its performance outside the ED. ED patients are, by their very nature, "emergent." Some procedures are performed in the ED on patients who ultimately die in the ED or shortly after transfer to another unit. Waiting for full stabilization may not be appropriate, but such patients would never be part of a non-ED study of TEE. Lastly, quite appropriately, the authors highlight the fact that respiratory insufficiency/failure was the most common complication of ED TEE. Airway management always assumes priority over all other issues, and though no cause and effect conclusion can be drawn from this study, ED airway management must be aggressive with not just a reactionary, but also an anticipatory, approach to complications.
Reference
1. Smith MD, et al. Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta. N Engl J Med 1995;332:356-362.
2. Pearson AC, et al. Safety and utility of transesophageal echocardiography in the critically ill patient. Am Heart J 1990;119:1083-1089.
TEE in the ED:
a. may have greater complications than in non-ED settings due to the emergent nature of the patients being evaluated.
b. is safe in medical, but not trauma, patients.
c. does not cause complications if patients undergo prior intubation.
d. is better than aortography in diagnosing aortic rupture.
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