Safety of Transesophageal Echocardiography Performed by Intensivists and Emergency Physicians in Critically Ill Patients With Coagulopathy and Thrombocytopenia: A Single-Center Experience

Abstract

Introduction: The use of transesophageal echocardiography (TEE) by intensivist physicians (IPs) and emergency physicians (EPs) in critically ill patients is increasing in the intensive care unit, emergency department, and prehospital environments. Coagulopathy and thrombocytopenia are common in critically ill patients. The risk of performing TEE in these patients is unknown. The goal of this study was to assess whether TEE is safe when performed by IPs or EPs in critically ill patients with high bleeding risk (HBR). Methods: All TEEs performed by an IP or EP between January 1, 2016, and July 31, 2019, were reviewed as part of a quality assurance database. A TEE performed on a patient was deemed HBR if the patient met at least one of the following criteria: undergoing therapeutic anticoagulation, had an INR > 2, activated partial thromboplastin time >40 seconds, fibrinogen <150 mg/dL, and/or platelet count <50 000/μL. The medical record was reviewed on each patient to determine whether upper esophageal bleeding, oropharyngeal bleeding, esophageal perforation, or dislodgement of an artificial airway occurred during or after the TEE. Results: A total of 228 examinations were reviewed: 80 in the high-risk group and 148 in the low-risk group (LBR). There were complications potentially attributable to TEE in 8 (4%) of the 228 exams. Total complications were not different between groups: 4 (5%) in the HBR group versus 4 (3%) in the LBR group (odds ratio [OR] = 1.89 [0.34-10.44], P =.368). Upper esophageal bleeding occurred in 5 total examinations (2%), which was not different between groups: 3 (4%) in the HBR group and 2 (1%) in the LBR group (OR = 2.84 [0.31-34.55], P = .238). There were no deaths attributable to TEE in either group. Conclusion: Transesophageal echocardiography can be safely performed by IPs and EPs in critically ill patients at high risk of bleeding with minimal complications.

Transesophageal Echocardiography Performed by Intensivist and Emergency Physicians—A 5-Year, Single-Center Experience

“…This is consistent with other publications. 14,15 A large proportion (107 exams, 43%) of patients died within 7 days of having TEE performed. This reflects the patient acuity when TEE was performed but does limit the evaluation of complications as autopsy data unavailable.…”

Feasibility, utility, and safety of fully incorporating transesophageal echocardiography into emergency medicine practice

“…Although we did not have any cases of bleeding in this study, it is a potential concern because the coagulation status of ED patients is usually not known at the time of the F‐TEE examination. However, a recently published series of critically ill patients with coagulopathy or thrombocytopenia who underwent F‐TEE showed that these patients did not have a higher risk of bleeding after the procedure 57 . A review of the literature for esophageal perforation associated with TEE examinations found four studies including 20,000 patients, with four reported cases of esophageal perforation for a rate of 0.02% 58–61 .…”

Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade

“…In recent years, the usage of TEE has escalated in the emergency department (ED) and critical care, and this trend is well documented in the literature [13][14][15][16][17][18][19][20][21][22]. Focused or resuscitative TEE are terms used to describe the usage of limited TEE views to facilitate early recognition of pathologic processes and to guide clinical decision-making in critically ill patients [13][14][15].…”

“…Focused TEE in the ED is beneficial in the management of cardiac arrest [17,18] undifferentiated shock [19] and trauma [20,21]. The use of TEE by non-cardiologists in the ED and intensive care setting for critically ill patients is safe [22] and extremely useful in resource-limited setting [23]. However, focused TEE does not replace the need for comprehensive TEE when clinical questions exceed the scope of a limited exam.…”