Can a confused patient undergo a Transesophageal Echocardiogram (TEE)?

Can a Confused Patient Undergo TEE?

Yes, a confused patient can undergo transesophageal echocardiography (TEE), but the procedure requires careful risk-benefit assessment, appropriate sedation, and consideration of the clinical urgency and specific contraindications.

Clinical Context and Decision Framework

The ability to perform TEE in a confused patient depends primarily on:

• Clinical urgency of the indication - TEE should only be performed when it provides essential diagnostic information that will change management 1
• Ability to secure the airway and provide adequate sedation - Confused or agitated patients typically require deeper sedation or general anesthesia to tolerate the procedure 1, 2
• Presence of absolute contraindications - Active esophageal pathology, recent esophageal surgery, or high risk of perforation 2, 3

When TEE is Justified in Confused/Critically Ill Patients

TEE is specifically indicated in hemodynamically unstable or critically ill patients when transthoracic imaging is inadequate, which commonly includes confused patients in intensive care settings 1:

• Hemodynamically unstable patients with suboptimal TTE images - This is a Class I indication 1
• Mechanically ventilated patients - TEE often provides superior imaging in intubated patients 1
• Suspected aortic dissection - This is an urgent/emergent indication where TEE is the procedure of choice 1
• Suspected aortic injury or major trauma - TEE is preferred for definitive diagnosis 1
• Cardiac arrest or periarrest states - TEE has demonstrated utility and safety in resuscitative settings 4, 5

Practical Considerations for Confused Patients

Sedation Requirements

• Most conscious patients undergoing TEE do not require intravenous sedation 6
• However, confused or agitated patients will typically require moderate to deep sedation or general anesthesia to ensure patient safety and procedural success 1, 2
• In one large series, 4-5% of patients required general anesthesia for TEE 7

Safety Profile

TEE has an acceptable safety profile even in critically ill patients 2, 6, 5:

• Mortality rate is extremely low (0.0098%) in a multicenter survey of over 10,000 examinations 6
• Unsuccessful probe insertion occurs in only 1.9% of cases, primarily due to lack of patient cooperation or operator inexperience 6
• Procedure interruption due to patient intolerance occurs in 0.88% of successful insertions 6
• In emergency medicine practice, TEE was successfully performed with interpretable images in 99% of critically ill patients 4

Absolute Contraindications

Do not perform TEE if the patient has 2, 3:

• Recent food intake within 4-6 hours (unless emergent indication outweighs aspiration risk)
• Known esophageal pathology (stricture, tumor, diverticulum, recent surgery)
• Active upper gastrointestinal bleeding
• Suspected esophageal perforation
• Severe cervical spine instability

Alternative Approaches

If TEE cannot be safely performed, consider 1:

• Off-axis transthoracic views - May provide adequate information in some cases 1
• Contrast-enhanced TTE - Ultrasound-enhancing agents can improve transthoracic image quality 1
• Cardiac CT or MRI - May be alternatives for specific indications (e.g., left atrial appendage thrombus), though these require patient transport and cooperation 1
• Epicardial echocardiography - Can be considered in surgical settings when TEE is contraindicated 2

COVID-19 and Infectious Disease Considerations

TEE carries heightened risk for aerosolization and disease transmission 1:

• TEE may provoke coughing or gagging, leading to viral aerosolization in COVID-19 or other respiratory infections 1
• Postpone or cancel TEE if alternative imaging can provide necessary information in patients with suspected or confirmed infectious respiratory illness 1
• Appropriate personal protective equipment is essential when TEE must be performed 1

Key Clinical Pitfalls

• Do not perform TEE for "routine" or elective indications in confused patients - The procedure should only be done when findings will immediately impact management 1
• Ensure adequate sedation and airway protection - Inadequate sedation increases risk of esophageal trauma and procedure failure 2, 6
• Verify NPO status - Recent food intake significantly increases aspiration risk, though this may be accepted in true emergencies 2, 3
• Have appropriate monitoring and resuscitation equipment available - TEE in critically ill patients requires full ICU-level support 5