What are the pre‑procedure, intra‑procedure, and post‑procedure orders for a transesophageal echocardiogram (TEE)?

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Last updated: March 11, 2026 • View editorial policy

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TEE Orders: Pre-Procedure, Intra-Procedure, and Post-Procedure Protocol

For transesophageal echocardiography, implement a systematic three-phase approach with specific pre-procedure preparation including NPO status and anticoagulation assessment, intra-procedure monitoring with comprehensive multiplane imaging, and post-procedure surveillance for complications and documentation of findings. 1

Pre-Procedure Orders

Patient Preparation and Consent

  • Obtain informed consent after discussing risks including esophageal perforation, bleeding, and aspiration 1
  • Verify NPO status: minimum 6-8 hours for solids, 2 hours for clear liquids to reduce aspiration risk 1
  • Review contraindications: active esophageal pathology, recent esophageal surgery, esophageal stricture, or varices 1

Anticoagulation Management

  • For cardioversion or atrial fibrillation/flutter >48 hours: confirm therapeutic anticoagulation (INR 2.0-3.0) for at least 3 weeks prior, or plan for immediate anticoagulation if TEE shows no thrombus 2, 3
  • Document anticoagulation status and bleeding risk factors 2
  • Do NOT discontinue anticoagulation for diagnostic TEE unless specific bleeding concerns exist 2

Pre-Procedure Testing

  • Verify recent labs: complete blood count, coagulation studies if on anticoagulation 1
  • Perform transthoracic echocardiography first in most cases, as TEE should complement rather than replace TTE 4, 5
  • Review prior imaging and surgical history to guide focused examination 6

Medication Orders

  • Topical anesthesia: lidocaine spray or viscous lidocaine for oropharyngeal anesthesia 1
  • Conscious sedation: midazolam 1-2 mg IV and/or fentanyl 25-50 mcg IV titrated to effect 1
  • Have reversal agents available: flumazenil and naloxone 1
  • Antisialagogue: consider glycopyrrolate 0.2 mg IV to reduce secretions 1

Equipment and Personnel

  • Ensure availability of: bite block, suction, oxygen, monitoring equipment, emergency airway equipment 1
  • Require credentialed operator: fellowship-trained cardiac anesthesiologist or cardiologist with TEE certification 7, 1

Intra-Procedure Orders

Monitoring Requirements

  • Continuous monitoring: ECG, pulse oximetry, blood pressure every 3-5 minutes, capnography if heavily sedated 1
  • Maintain oxygen saturation >90% with supplemental oxygen as needed 1

Systematic Imaging Protocol

Follow a standardized multiplane examination sequence to ensure comprehensive assessment and avoid omissions 6, 8:

Mid-Esophageal Views (0° to 165°)

  • Start at 0°-20°: four-chamber view for ventricles, mitral valve, tricuspid valve, atrial septum 6
  • 30°-60°: aortic valve short-axis view 6
  • 60°-70°: mitral valve commissural view 6
  • 80°-110°: bicaval view for atrial septum, two-chamber view, right ventricular inflow-outflow 6
  • 120°-160°: long-axis views of left ventricle, aortic valve, mitral valve 6

Transgastric Views

  • Advance probe to stomach for basal short-axis (0°-20°), mid short-axis (0°-20°), two-chamber (80°-100°), long-axis (90°-120°), and deep transgastric views (0°-20° with anteflexion) 6

Upper Esophageal Views

  • Withdraw probe systematically to assess ascending aorta, aortic arch, descending thoracic aorta, main pulmonary artery 6

Specific Assessments Based on Indication

For cardioversion/atrial fibrillation: Focus on left atrial appendage thrombus exclusion, spontaneous echo contrast, and left atrial size 2, 3

For valve surgery: Detailed valve morphology, mechanism of regurgitation, suitability for repair, ventricular function 4, 9

For endocarditis: Vegetation size and location, abscess formation, valve destruction, hemodynamic consequences 5

For intraoperative monitoring: Ventricular function, volume status, regional wall motion abnormalities, adequacy of surgical repair 7, 10, 1

Contrast Administration

  • Use agitated saline contrast when evaluating for intracardiac shunts (ASD, PFO), anomalous venous connections, or right-to-left shunts 6, 11

Post-Procedure Orders

Immediate Post-Procedure Care

  • Monitor vital signs every 15 minutes until stable and sedation wears off 1
  • Maintain NPO status for 1-2 hours until gag reflex returns and topical anesthesia wears off 1
  • Assess for complications: chest pain, dysphagia, hematemesis, respiratory distress 1

Complication Surveillance

  • Watch for esophageal perforation signs: severe chest or back pain, subcutaneous emphysema, fever, dysphagia 1
  • Monitor for aspiration: cough, hypoxemia, fever developing within 24 hours 1
  • Assess for bleeding: hematemesis, melena, hemodynamic instability 1

Documentation Requirements

Complete comprehensive report including 6:

  • Pre-intervention findings: all standard views, specific pathology identified, quantitative measurements
  • Post-intervention findings (if applicable): assessment of surgical/procedural results, new abnormalities
  • Conclusions: overall interpretation, assessment of indication, comparison to prior studies, study limitations, recommendations for additional testing

Anticoagulation Management Post-TEE

  • If TEE performed for cardioversion and no thrombus found: initiate or continue therapeutic anticoagulation immediately with LMWH or IV heparin, then transition to oral anticoagulation for minimum 4 weeks post-cardioversion 2, 3
  • If thrombus identified: continue anticoagulation for 4 weeks, repeat TEE to confirm resolution before cardioversion 3

Follow-Up Orders

  • Discharge when: fully awake, vital signs stable, gag reflex returned, no complications identified 1
  • Diet advancement: start with clear liquids, advance as tolerated if no dysphagia 1
  • Activity: no driving or operating machinery for 24 hours if sedation used 1
  • Contact instructions: return immediately for severe chest pain, difficulty swallowing, vomiting blood, or respiratory distress 1

Special Considerations

COVID-19 Era Precautions

TEE is an aerosol-generating procedure requiring enhanced PPE (N95 respirator, face shield, gown, gloves) for suspected or confirmed COVID-19 patients 12. Defer elective TEE during outbreaks and consider alternative imaging (contrast TTE, cardiac CT, cardiac MRI) when possible to conserve PPE and reduce exposure risk 12.

Pediatric Modifications

Use TEE cautiously in small children due to risks of bronchial obstruction and esophageal injury; consider case-by-case basis with appropriately sized probes 1.

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.