Perioperative TEE Rotation

The perioperative TEE rotation is comprised of dedicated weeks reserved for TEE in the operating room. Fellows are responsible for performing TEEs in all adult cardiac surgery cases, in non-cardiac surgery cases requesting TEE consult and in the cardiothoracic intensive care unit (CT-ICU 7W). Attending anesthesiologists will provide instruction and guidance on image acquisition, optimization, interpretation and communication to the surgical team. All images are acquired and stored digitally on the hard drives of the TEE machines for later transfer to the image server (Xcelera). Fellows then enter reports on a web-based form and hand off to the responsible attending physicians for e-signatures. Please use your assigned DHE user ID and password to log into TEE on the Web reporting system tee.duhs.duke.edu.

For reviewing cases on the image server, access Xcelera from any Patient Information Network (PIN) station in the hospital, from the stand-alone desktop in the Fellows’ office or from the stand-alone desktop or the PIN station in the TEE simulation lab (room 5680 HAFS building).

The first TEE rotation will start with a period of one week spent in the Cardiology Echo laboratory (Duke South Clinic 2K) where fellows will learn the basics of ultrasound imaging, knobology of echo machines, standard chest wall imaging techniques and interpretation, and daily didactic teaching activities with sonographers and cardiology faculty. Contact information and formal goals and objectives regarding the Echo Lab week will be sent to you by email.

General Guidelines

  1. For your TEE week, please sign over coverage for the echo pager (970-ECHO or 970-3246) to your pager. To do this, simply dial 970-3246; press *#; then press ‘1’; and follow instructions to change coverage to your pager ID. Please do this at the beginning of each week.
  2. The TEE probes will be in the “Clean Probe” cabinet next to the anesthesia cart. On occasion you may have to get a probe from the anesthesia workroom or from the probe cleaning room in Duke North.
  3. OR induction starts at 6:30 a.m. each morning, except for Wednesdays, when induction of anesthesia is at 8:20 a.m.
  4. Please be ready to place the TEE probe after induction of general anesthesia and perform the pre-procedure TEE around time.
  5. Ensure three EKG leads are connected and a clear signal is obtained or ensure that you are capturing the ECG signal from the anesthesia monitor before starting image acquisition.
  6. Empty stomach with OG tube.
  7. Bite-guard must be used in all cases. Lubricate the oropharynx with surgical lubricant, NOT with the surface ultrasound gel (blue gel in the bottle with the red cap).  Please use a laryngoscope to facilitate TEE probe insertion. If in doubt, or if you encounter resistance, please call the attending.
  8. Ensure correct patient information on the images/loops banner.
  9. Use the TEE probe holder in all cases.
  10. After the TEE probe has been used and the exam completed, the probe will be removed from the patient and wiped down with special enzymatic cleaning sponges present in the OR wall cabinets behind the anesthesia machines.  The dirty TEE probe will then be placed in the cabinet marked “Dirty probe” or be handed over directly to  (a) Dheadra McAdoo – 970-0830 (or whomever is covering her that day); or (b) the anesthesia technician.  If you place the probe in the “Dirty probe” cabinet you do not have to use a red bag. If you hand the probe directly to an anesthesia tech please place the probe in a red bag.
  11. PLEASE BE VERY CAREFUL WHEN HANDLING THE PROBES. THEY ARE VERY EXPENSIVE.
  12. If you have any difficulties with reports – hardware (machine), software (TOW isn’t working) or signing reports, please let dr. Alina Nicoara (970-9221) know at the earliest opportunity.
  13. If you have any questions related to your TEE rotation please contact dr. Alina Nicoara (970-9221, 303-818-6310)

Performing the TEE Exam and Reporting

  1. VERY IMPORTANT: Review images with the attending anesthesiologist on the case after you have performed the prebypass and the postbypass exams. Unexpected findings may alter the surgical procedure, lead to surgical intervention prior to leaving the OR, or mismanagement in the ICU if not communicated properly.
  2. If you anticipate that the case will go beyond 7 p.m., inform the attending for the case that you will not be available for the post-procedure exam and that you will enter the TEE report the following morning from recorded loops. Please remind the attending to complete the post-procedure exam. Retrieve the images and data from the machine or from Xcelera after Dheadra has loaded the study. If there are doubts about the exam, please discuss pertinent clinical information with the attending anesthesiologist prior to entering the final report
  3. Please complete your reports within one working day. That would mean signing or handing off your reports on the web-based database (TEE on the web or TOW) within 24 hours of an exam or on the first working day after a holiday or weekend.
  4. For studies done over the weekend, please check the EPIC snapboard for cases performed or discuss with the fellow on call over the weekend; go over the images on Xcelera and discuss with attending anesthesiologist who was responsible for the case, and enter data into TOW.
  5. Please enter your report for the first case of the day by the afternoon the same day

Exams Performed Out of the Cardiac Operating Room

  1. We perform exams in the Cardiothoracic Unit (CT ICU) 7W Duke Medicine Pavilion and in the noncardiac rooms. The TEE exams in the Medical ICU, Surgical ICU, Neuro ICU are performed by the cardiology service, unless it is a STAT exam or the cardiology staff is not unavailable.
  2. In general, follow the same guidelines when performing a TEE exam in the CT-ICU (7 West unit) as well.
  3. In case of an urgent call from a non-cardiac OR, please notify cardiac attending covering the 970-1699 pager that day and proceed to perform the exam. Discuss clinical need for performing TEE with the attending who has requested the exam.  If the patient is already under general anesthesia ask about comorbidities or conditions, which may be a contraindication to placing a TEE probe. Discuss with the 970-1699 cardiac attending prior to making any therapeutic decisions in the non-cardiac OR. Follow same steps for doing the TEE exam as above.

FAQ

I need a probe and it’s not in the OR

  1. Ask your anesthesia technician.
  2. If during daytime hours (6:30-3:30 pm) please page Dheadra Mcadoo (970-0380, our dedicated perioperative TEE technician).

I got paged to do an echo in 7W CT ICU

  1. If the TEE exam has to be performed in the 7 West unit, use the CX50 Philips machine but ask the anesthesia technician or the perioperative TEE technician (Dheadra McAdoo or equivalent) to bring the TEE probe for this machine.
  2. Bring sponge, red biohazard bag for after removal; return equipment to OR

The TEE probe does not work/ is broken

  1. Label probe as malfunctioning on handle, take note of probe number.
  2. Call or email Dheadra or Dr. Nicoara with problem and probe number
    1. If you simply label broken, often the tape can be removed, probe cleaned, recirculated, and then inserted into a patient before anyone notices it is broken.

The TEE machine does not work/unexpectedly turned off

  1. Page perioperative TEE technician (Dheadra or equivalent) if within working hours. Email Dheadra McAdoo and Dr. Nicoara with the TEE machine number. Continue the TEE exam with an unused machine from another room. If the TEE exam is on two different machines, inform Dheadra McAdoo to merge the two exams.

Can’t find patient on Xcelera

  1. Check that the search boxes are adequate (exam date, type of exam, location).
  2. Patient’s exam may not have been downloaded from the TEE machine (especially if performed at night or in non cardiac OR)
  3. Patient’s name or medical record number may be misspelled or completely wrong. In this case contact Dheadra via page or email and she may be able to locate it for you.

Can’t insert probe into machine

  1. DO NOT FORCE IT!
  2. Remove the cover on the connector. Make sure that the connector is ‘unlocked’ when inserting (the knob on the connector should be in horizontal position). Turn the knob on the surface of the connector counterclockwise into vertical position after insertion.
  3. Try different port.
  4. Check for bent pins if not inserting easily, probe may need to be repaired

Probe will not pass oropharynx/can’t advance into stomach

  1. DO NOT FORCE IT! If you can’t use 2 fingers to advance it, you are using too much force.
  2. Always use surgical lubricant.
  3. Use a laryngoscope.
  4. Try jaw thrust, head flexion and/or gently rotation of the probe.
  5. Call attending for help if the first 2-3 attempts are unsuccessful.

Tips for TEE on the web

  1. Always use “Search Schedule” or “Search by MRN” to avoid mistakes in entering patient information.
  2. The website is down: call IT (919-684-2243) ASAP, as it often takes hours to fix the problem

Faculty and Staff

Faculty

Solomon Aronson, MD, Echo Faculty
Brandi Bottiger, MD, Echo Faculty
Anne Cherry, MD, Echo Faculty
Brian Colin, MD, Echo Faculty
J. Mauricio Del Rio, MD, Echo Faculty
Nicole Guinn, MD, Echo Faculty
Jorn Karhausen, MD, Echo Faculty
Miklos Kertai, MD, Echo Faculty
Rebecca Klinger, MD, Echo Faculty
Yasmin Maisonave, MD, Echo Faculty
Michael Manning, MD, Echo Faculty
Joseph Mathew, MD, Echo Faculty
Mark Newman, MD, Echo Faculty
Alina Nicoara, MD, Echo Faculty
Mihai Podgoreanu, MD, Echo Faculty
Mark Stafford-Smith, MD, Echo Faculty
Madhav Swaminathan, MD, Echo Faculty
Eleanor Vega, MD, Echo Faculty
Ian Welsby, MB, Echo Faculty

Staff

Jaime Cooke, Staff Assistant
Audrey McGregor, Staff Assistant
Dheadra McAdoo, Echo Technician
Cheryl Stetson, CT Fellowship Coordinator