What types of anesthesia are used during a Transesophageal Echocardiogram (TEE)?

From the Guidelines

Conscious sedation is the preferred type of anesthesia used during a Transesophageal Echocardiogram (TEE), as it allows for prompt detection of adverse neurological events and has been associated with fewer requirements for inotropes/vasopressors, shorter lengths of hospital stay, and shorter procedural/intervention times. The anesthetic plan for conscious sedation should use the fewest medications at the lowest doses needed to control pain and anxiety, taking into account the patient's age, frailty, and multiple comorbidities 1.

Types of Anesthesia Used

• Topical anesthesia, such as lidocaine, may be applied to the back of the throat to suppress the gag reflex
• Conscious sedation using medications like midazolam, fentanyl, or propofol may be used to provide anxiolysis and pain control while maintaining respiratory drive
• General anesthesia may be used in some cases, especially for patients who cannot tolerate conscious sedation or have difficulty cooperating, although this is less common 1

Key Considerations

• Monitoring of vital signs, oxygen saturation, and level of sedation is essential throughout the procedure
• Patients should not eat or drink for at least 6 hours before the procedure to reduce the risk of aspiration
• The procedure typically lasts 15-30 minutes, and patients remain responsive but comfortable during this time 1.

From the FDA Drug Label

Maintenance Dose: Additional doses to maintain the desired level of sedation may be given in increments of 25% of the dose used to first reach the sedative endpoint, but again only by slow titration, especially in the elderly and chronically ill or debilitated patient Induction of Anesthesia: For induction of general anesthesia, before administration of other anesthetic agents. Injectable midazolam can also be used during maintenance of anesthesia, for surgical procedures, as a component of balanced anesthesia.

Types of Anesthesia Used During TEE:

• Midazolam (IV): used for sedation and induction of anesthesia
• Inhalational anesthetics: may be used to complete induction
• Narcotic premedication: such as fentanyl, morphine, and meperidine, may be used in conjunction with midazolam
• Opioid analgesics: may be administered concurrently with midazolam to reduce the minimum effective infusion rate 2
• Balanced anesthesia: midazolam may be used as a component of balanced anesthesia for surgical procedures 2

From the Research

Types of Anesthesia Used During TEE

• Topical anesthesia is commonly used during Transesophageal Echocardiogram (TEE) procedures, with benzocaine spray being a frequently used agent 3, 4.
• However, benzocaine has been associated with a rare but potentially life-threatening condition called methemoglobinemia 3, 4.
• Lidocaine is another topical anesthetic agent used during TEE, and studies have shown that it can cause a mild increase in methemoglobin levels, but this is not typically clinically significant 5.
• General anesthesia may also be used in some cases, particularly in the operating room setting, where TEE is used to assist with surgical decision-making 6.

Considerations for Anesthesia Use During TEE

• The choice of anesthesia used during TEE should be carefully considered, taking into account the patient's medical history and any potential risks or contraindications 7.
• Physicians performing TEE should be aware of the potential complications associated with topical anesthesia, including methemoglobinemia, and have the necessary treatment readily available 3, 4.
• The use of TEE in non-cardiac surgery is still evolving, and more studies are needed to support its use outside of cardiac surgery at its full potential 7.