Critical Care Transesophageal Echocardiography in Patients during the COVID-19 Pandemic

Abstract

Background: The COVID-19 pandemic has placed an extraordinary strain on healthcare systems across North America. Defining the optimal approach for managing a critically ill COVID-19 patient is rapidly changing. Goaldirected transesophageal echocardiography (TEE) is frequently used by physicians caring for intubated critically ill patients as a reliable imaging modality that is well suited to answer questions at bedside. Methods: A multidisciplinary (intensive care, critical care cardiology, and emergency medicine) group of experts in point-of-care echocardiography and TEE from the United States and Canada convened to review the available evidence, share experiences, and produce a consensus statement aiming to provide clinicians with a framework to maximize the safety of patients and healthcare providers when considering focused point-of-care TEE in critically ill patients during the COVID-19 pandemic. Results: Although transthoracic echocardiography can provide the information needed in most patients, there are specific scenarios in which TEE represents the modality of choice. TEE provides acute care clinicians with a goal-directed framework to guide clinical care and represents an ideal modality to evaluate hemodynamic instability during prone ventilation, perform serial evaluations of the lungs, support cardiac arrest resuscitation, and guide veno-venous ECMO cannulation. To aid other clinicians in performing TEE during the COVID-19 pandemic, we describe a set of principles and practical aspects for performing examinations with a focus on the logistics, personnel, and equipment required before, during, and after an examination. Conclusions: In the right clinical scenario, TEE is a tool that can provide the information needed to deliver the best and safest possible care for the critically ill patients.

COVID-19 cardiac arrest management: A review for emergency clinicians

“…The use of transesophageal echocardiography (TEE) during cardiac arrest may optimize the quality of chest compressions and provide additional diagnostic information regarding the cause of the arrest [ 84 ]. The ability to perform TEE in proned patients and its low risk of viral aerosolization in already intubated patients has led to a consensus statement by a multidisciplinary group of experts in point-of-care echocardiography to recommend its use in COVID-19 patients [ 84 ].…”

Joint Recommendations and Resources for Clinical Ultrasound Education Amidst the COVID‐19 Era

“…2,3 Additionally, CUS may limit the need for patient transportation for imaging, reduce the number of health care workers (HCW) in contact with COVID-19-positive patients and those who are persons under investigation (PUI), reduce PPE usage, and address concerns about infection control as the CUS devices, particularly handheld devices, are more easily disinfected. 4 Social distancing, which is effective in reducing viral transmission, is antithetical to CUS education, which requires direct hands-on supervision to achieve competence. CUS education supports a heterogeneous group of learners, ranging from preclinical medical students to ultrasound fellows, with different learning styles and supervisorial needs.…”

“…COVID‐19 patients are prone to lung pathology, cardiomyopathy, renal injury, and volume status compromise, and CUS may improve the diagnosis and management of these conditions 2,3 . Additionally, CUS may limit the need for patient transportation for imaging, reduce the number of health care workers (HCW) in contact with COVID‐19–positive patients and those who are persons under investigation (PUI), reduce PPE usage, and address concerns about infection control as the CUS devices, particularly handheld devices, are more easily disinfected 4 …”

Echocardiography, Lung Ultrasound and Cardiac Magnetic Resonance Findings in COVID-19: A Systematic Review

“…TEE guidance can help confirm the course of a guidewire during insertion and help in excluding coiling of the guidewire in the right atrium, crossing of the guidewire across the interatrial septum or its entrance in the coronary sinus. It can also ensure that the return cannula is positioned clear of the interatrial septum and the tricuspid valve, thereby reducing the risk for recannulation [67][68][69][70][71]. TEE can also help identify the cause for worsening hypoxemia during ECMO which includes scenarios where the cannula tips are too close to each other causing recirculation, hypovolemia causing inadequate ECMO flow and thrombus formation in the cannula which may be impeding adequate flow [66].…”