What is the nothing by mouth (NPO) status for Transesophageal Echocardiogram (TEE)?

From the Guidelines

For a transesophageal echocardiogram (TEE), patients may be allowed to consume clear liquids up to 2 to 4 hours before the procedure, but solid food should be avoided for at least 6 hours, as recommended by the enhanced recovery after surgery society guidelines 1. When considering the guidelines for perioperative care in cardiac surgery, it's essential to prioritize the patient's safety and prevent potential complications such as aspiration pneumonitis.

• The guidelines suggest that clear liquids can be safely given up to 2 hours before the induction of anesthesia, and a light meal can be given up to 6 hours before elective procedures requiring general anesthesia 1.
• However, it's crucial to note that these recommendations are based on evidence from noncardiac surgery populations, and limited studies have been conducted specifically on cardiac surgery patients.
• A small study in patients undergoing cardiac surgery demonstrated that an oral carbohydrate drink consumed 2 hours preoperatively was safe, and no incidents of aspiration occurred 1.
• Nevertheless, the risk of aspiration remains, particularly in patients with delayed gastric emptying due to diabetes mellitus or those undergoing transesophageal echocardiography.
• Morning medications can typically be taken with small sips of water, except for anticoagulants, which may need to be held depending on physician guidance.
• Diabetic patients may need adjusted medication schedules to prevent hypoglycemia during the fasting period.
• Patients should also inform their provider about any allergies, medications, or medical conditions before the procedure.

From the Research

NPO for TEE

• The practice of fasting before elective cardiac procedures, including transesophageal echocardiography (TEE), is commonly implemented, but evidence for these requirements is lacking 2.
• Fasting periods often exceed the intended length of time, increasing the risk of irritability, dehydration, acute kidney injury, hypoglycemia, and length of hospitalization 2.
• Transesophageal echocardiography should not be performed in patients who consumed a meal 4-6 hours before the test, or when there is a risk of esophageal perforation and massive gastrointestinal bleeding 3.
• However, the evidence has shown that fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines 2.
• Elective cardiac procedures, including TEE, are performed using procedural sedation, where the risk of serious aspiration is small, and strict fasting requirements should be reduced, and a more nuanced fasting protocol based on individual patient characteristics and risk factors should be utilized 2.

Indications and Contraindications for TEE

• Primary indications for transesophageal echocardiography include an assessment of cardiac source of embolism, suspected endocarditis, suspected prosthetic valve dysfunction, an assessment of thoracic aorta and other vessels, an assessment prior to valvular repairs and closures of septal defects, intraoperative monitoring of cardiac or percutaneous interventions, ablation, non-diagnostic transthoracic examination, especially in patients after cardiac surgeries 3.
• Contraindications for TEE include patients who consumed a meal 4-6 hours before the test, or when there is a risk of esophageal perforation and massive gastrointestinal bleeding 3.

Procedure and Safety

• Transesophageal echocardiography is performed using a multiplanar probe, which ensures the best conditions for imaging of the heart and the thoracic aorta 3.
• Serious complications after transesophageal examination are very rare 3.
• The test should be performed in an appropriately accredited laboratory and by a cardiologist with an individual accreditation 3.
• Transesophageal examination requires patient consent 3.