Resuscitative TEE Pearls

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BY FELIPE TERAN MD 

ERGONOMICS OF PERFORMING POINT-OF-CARE TEE

DELIBERATELY CHOOSE A TECHNIQUE TO HOLD THE PROBE (YOU NEED TO BE ABLE TO OPERATE THE PROBE WITHOUT LOOKING AT THE CONTROLLER)

“BRONCHOSCOPY-STYLE” (MY PREFERRED TECHNIQUE): controller hand with wheels facing up, STRAIGHT SHAFT TO THE MOUTH. PROVIDES THE MOST ERGONOMIC GRAB – CONTROL OF BOTH WHEELS WITH FINGERS AND OMNIPLANE BUTTONS AND ALLOWS TRANSFERENCE OF ROTATION MOVEMENTS WITH WRIST MOVEMENTS ON THE CONTROLLER HAND.

“FISHING ROD STYLE" TECHNIQUE: LOW GRAB, WITH CURVED PROBE SHAFT. THIS TECHNIQUE IS MOST COMMONLY USED BY CARDIOLOGISTS SCANNING AT THE BEDSIDE. IN MY OPINION, A LESS ERGONOMIC GRAB OF THE CONTROLLER (IF THE WHEELS ARE FACING UP - CAN’T HOLD THE CONTROLLER AND OPERATE WHEELS AT THE SAME TIME). WORKS BEST WHEN USING TWO HANDS IN THE CONTROLLER. NOT A GOOD TECHNIQUE FOR HEAD OF THE BED POSITIONING.

“BRONCHOSCOPY-STYLE”

“FISHING ROD STYLE" 

LOGISTICS OF PERFORMING TEE DURING RESUSCITATION

• USE A DEDICATED MACHINE. ANOTHER MACHINE WILL BE NEEDED FOR VASCULAR ACCESS AND PROCEDURAL GUIDANCE.
• LEARN AND PRACTICE TO SCAN STANDING AT THE HEAD OF THE BED (THIS IS A REASON TO PREFER TRAINING WITH ANESTHESIA IN OR VS CARDIOLOGY).
• IF YOU ARE RIGHT HANDED – AND USE “BRONCHOSCOPY-STYLE” TECHNIQUE TO HOLD THE PROBE, THEN MACHINE SHOULD BE LOCATED ON THE LEFT SIDE OF THE PATIENT (FROM THE HEAD OF THE BED PERSPECTIVE). THIS IS BECAUSE THE TEE PROBE CORD WILL NOT BE LONG ENOUGH TO COMFORTABLE SCAN HOLDING PROBE WITH LEFT HAND IF MACHINE IS LOCATED ON THE OPPOSITE SIDE.
• Ideally HAVE SOMEONE HELP WITH THE MACHINE KNOBS FOR IMAGE OPTIMIZATION AND SAVE CLIPS (AS YOU NEED BOTH HANDS TO OPERATE TEE)
• WEAR FACE SHIELD WITH MASK AND SURGICAL CAP FROM THE START. THIS WAY, IF THE PATIENT REQUIRES ANY STERILE PROCEDURE (CENTRAL LINE PLACEMENT OR ECMO CANNULATION ARE COMMON EXAMPLES) YOU WILL BE READY FOR IT. ONCE YOU START SCANNING, YOU WILL FIND YOURSELF WITH BOTH HANDS TAKEN.

UNDERSTANDING TEE PLANES AND IMAGE GENERATION

Image: TEE Simulator © HeartWorks

Image: TEE Simulator © HeartWorks 

• LEFT SIDE OF THE US BEAM FROM THE OPERATOR’S POV IS (MOST COMMONLY), THE RIGHT SIDE OF THE SCREEN. THIS WILL CHANGE WHEN THE OMNIPLANE IS ROTATED PASS 90 DEGREES.
•  VISUALIZE MOVEMENTS OF THE PROBE AND ULTRASOUND BEAM FROM PERSPECTIVE OF THE PROBE.
• USE PROBE’S POINT-OF-VIEW 3D IMAGE IN SIMULATOR TO TEACH AND LEARN THIS CONCEPT. IF YOU TRY TO UNDERSTAND THE MOVEMENT DIRECTIONS FROM MORE THAN ONE PERSPECTIVE (I.E. FROM THE FRONT OF THE PATIENT AND FROM THE HEAD OF THE BED / PROBE’S POV), YOU WILL MORE LIKELY GET CONFUSED.

PROBE INSERTION:

• UNDERSTANDING ANATOMY IS KEY: TECHNIQUE TO FACILITATE ESOPHAGEAL CANNULATION IS DIFFERENT THAN TECHNIQUE FOR ENDOTRACHEAL INTUBATION
• YOU WANT THE CHIN LIFT AND JAW THRUST BUT NOT THE NECK EXTENSION, BUT RATHER MILD ANTERIOR FLEXION OF NECK (AS IF INSERTING AN OG TUBE).
• MAIN TIP TO AVOID POSSIBILITY OF PHARYNGEAL INJURIES IS ENSURING THAT THE PROBE TIP IS FOLLOWING A MIDLINE PATH UNTIL REACHING THE BASE OF THE TONGUE.
• USE A BITE-BLOCK EVEN IF PATIENT IS IN ARREST. CLENCHING IS COMMON AND WILL CAUSE BOTH DIFFICULTY DURING PROBE INSERTION, AND POTENTIAL DAMAGE TO PROBE. IF YOU DON’T HAVE A BITE-BLOCK, A MEDIUM ORAL AIRWAY WILL DO IT.

UNDERSTAND POSSIBLE MOVEMENTS AND USE APPROPRIATE TERMS:

• MECHANICAL MOVEMENTS OF PROBE
  • ROTATION OF PROBE: LEFT AND RIGHT
  • ANTE AND RETROFLEXION OF PROBE
  • LATERAL FLEXION OF PROBE
• ELECTRONIC MOVEMENTS OF CRYSTALS
  • ROTATION OF OMNIPLANE (CLOCKWISE ROTATION OF OMNIPLANE FROM THE PERSPECTIVE OF THE PROBE)

DEVELOPING VIEWS:

UNDERSTAND 3D ANATOMY BEYOND THE HEART: SITUATION OF THE HEART IN THE CHEST AND SPATIAL RELATIONSHIP WITH GREAT VESSELS IS KEY:

• ESOPHAGUS
• AORTA
• POSITION OF THE HEART IN RELATION TO THE ESOPHAGUS
• RIGHT ATRIUM, SVC AND IVC
• PULMONARY ARTERIES

CONTROLLING THE PROBE DURING DESCENT: WHEN ENTERING ESOPHAGUS, ADVANCE SLOW AND LOOK FOR STRUCTURES SYSTEMATICALLY:

• GREAT VESSELS
• LONGITUDINAL VIEW OF THE AORTIC ARCH
• PULMONARY TRUNK AND PULMONARY ARTERIES
• FIND LEFT ATRIUM – SPECIFICALLY POINT WITH GREATEST DIAMETER (INDICATING THAT PROBE TIP IS RIGHT BEHIND THE MIDLEVEL OF THE LA). A COMMON NOVICE ERROR IS TO ADVANCE TOO MUCH, FIND VENTRICLES AND THEN HAVE FORESHORTENED ME 4C VIEW (DUE TO BEAM GENERATING VIEW FROM BELLOW THE BASE OF THE HEART). THIS IS ANALOG TO NOVICE INTUBATORS ADVANCING BLADE TOO FAR MISSING EPIGLOTTIS.

HAVE A SEQUENTIAL SCANNING TECHNIQUE: FOLLOW A SCANNING SEQUENCE EVERY SINGLE TIME, REGARDLESS OF THE DIFFICULTY OF THE SCAN. THIS WILL HELP YOU TO BE EFFICIENT WHEN SCANS ARE MORE DIFFICULT.  IT IS KEY TO KNOW THE LANDMARKS TO GENERATE THE VIEWS AND SPECIFICALLY TO BE SYSTEMATIC DURING TRANSITION BETWEEN VIEWS.

• A COMMON MISTAKE FROM NOVICES IS THAT THEY WILL START ROTATING THE OMNIPLANE BEFORE HAVING CENTERED THE BEAM IN THE STRUCTURE OF INTEREST. FOR INSTANCE, CENTER LV IN THE IMAGE IN ME 4 C VIEW BEFORE STARTING TO ROTATE TO DEVELOP ME LAX VIEW. ANOTHER EXAMPLE IS CENTERING THE RA IN THE SCREEN WHEN TRANSITIONING FROM ME 4 VIEW TO ME BICAVAL, BEFORE ROTATING TO 90 DEGREES.
• IF YOU GET LOST, DO NOT RANDOMLY KEEP ROTATING, INSTEAD RETURN TO ME 4 C VIEW.

SAFETY

ENSURE THE WHEEL’S LOCK IS UNLOCKED (AND THEREFORE PROBE IS BENDING FREELY) BEFORE INSERTION AND EXTUBATION. THIS IS PARTICULARLY IMPORTANT WHEN COMING OUT OF THE STOMACH TRANSITIONING FROM TRANSGASTRIC VIEWS BACK INTO ESOPHAGUS AS FLEXION OF THE PROBE REQUIRED DURING TRANSGASTRIC VIEWS CAN INJURE THE GASTROESOPHAGEAL JUNCTION.

ECMO-SPECIFIC PEARLS:

• DURING CANNULATION, CONFIRM PLACEMENT OF VENOUS GUIDEWIRE IN RA WITH BICAVAL VIEW PRIOR DILATION STAGE.
• VISUALIZE IN REAL TIME ADVANCEMENT OF VENOUS CANNULA AND CONFIRM OPTIMAL PLACEMENT AT THE IVC-RA JUNCTION .
• CONFIRM PLACEMENT OF ARTERIAL GUIDEWIRE CANNULATION IN MID ESOPHAGEAL VIEW OF THE DESCENDING AORTA SCANNING IN BOTH TRANSVERSE PLANE (OMNIPLANE AT 0 DEGREES) AND LONGITUDINAL PLANE (OMNIPLANE AT 90 DEGREES), PRIOR TO DILATION STAGE.
• IF ARTERIAL GUIDEWIRE IS NOT VISUALIZED IN THE DESCENDING AORTA, GO LOOK FOR THE WIRE IN THE IVC WITH BICAVAL VIEW.

TEACHING PEARLS

BREAKDOWN THE SKILLS REQUIRED FOR IMAGE ACQUISITION INTO STEPS:

1.    KNOWLEDGE OF TERMINOLOGY: PROBE ANATOMY AND POSSIBLE MOVEMENTS (MECHANICAL AND DIGITAL).

2.    UNDERSTANDING AND FAMILIARITY WITH CONTROLLERS: PROBE MANIPULATION AND ROLE OF EACH OF THE MOVEMENTS IS BETTER LEARNED WITHOUT INCORPORATING THE IMAGES.

3.    INTEGRATE THE ABOVE INTO SCANNING (ONLY WHEN GOALS 1 AND 3 HAVE BEEN MET).

USE DELIBERATE PRACTICE TO PRACTICE EACH OF THESE STEPS AND ASSESS THEM BEFORE MOVING INTO THE SCANNING PHASE (YOU WANT TO AVOID HAVING THE LEARNER LOOKING AT THE WHEEL OR THE BUTTONS, TRYING TO REMEMBER THE FUNCTIONS AT THE SAME TIME THAT LEARNER IS OPTIMIZING VIEW).