Critical Care Medicine-Neurologic Disorders>>>>>Imaging (Ultrasound)
Question 1#

A 34-year-old man with primary sclerosing cholangitis underwent orthotopic liver transplantation 6 hours ago. His other medical history includes obesity treated with sleeve gastrectomy 6 years ago, esophageal diverticulum, and peptic ulcer disease with remote gastrointestinal bleeding. He remains intubated and sedated in the ICU with current vital signs of:

He is currently receiving infusions of norepinephrine at 30 mcg/min and vasopressin at 0.04 units/min. He remains hypotensive despite rapid blood transfusion. An attempt at transthoracic cardiac ultrasound revealed no adequate windows. In deciding whether to perform a transesophageal echocardiogram (TEE) to work up his refractory shock, which of his medical problems would most likely be considered an absolute contraindication to TEE probe placement?

A. Esophageal varices
B. Prior gastric sleeve
C. History of bleeding peptic ulcer
D. Esophageal diverticulum

Correct Answer is D

Comment:

Correct Answer: D

Bedside cardiac ultrasound is indicated in critically ill patients when unexplained hypotension is present. If TEE views are not adequate, then a TEE examination is indicated. This patient has unexplained hypotension following liver transplantation despite high doses of vasopressors and has not demonstrated volume responsiveness. Cardiac ultrasound is required to rule out pathology such as right or left ventricular dysfunction, acute valvular disorders, and hemodynamically significant pericardial effusion. Because no transthoracic views could be obtained, transesophageal echocardiography would offer insight into cardiac function.

According to the ASE/SCA Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination, the absolute contraindications for TEE probe placement include:

  1. Perforated viscus
  2. Esophageal stricture
  3. Esophageal tumor
  4. Esophageal perforation, laceration
  5. Esophageal diverticulum
  6. Active upper GI bleed

The esophageal diverticulum would represent the absolute contraindication in this patient. The remainder of the patient’s pathology falls under relative contraindications. Of note, at many centers transesophageal echocardiography is a standard monitor during liver transplantation, even in patients with nonbleeding esophageal varices. A series of small studies has shown relatively good safety of TEE in patients with varices, though the risk of bleeding is higher than in the general population.

References:

  1. Dalia AA, Flores A, Chitilian H, Fitzsimons MG. A comprehensive review of transesophageal echocardiography during orthotopic liver transplantation. J Cardiothorac Vasc Anesth. 2018;32(4):1815-1824.
  2. Burger-Klepp U, Karatosic R, Thum M, et al. Transesophageal echocardiography during orthotopic liver transplantation in patients with esophagoastric varices. Transplantation. 2012;94(2):192-196.
  3. Spier BJ, Larue SJ, Teelin TC. et al. Review of complications in a series of patients with known gastro-esophageal varices undergoing transesophageal echocardiography. J Am Soc Echocardiogr. 2009;22(4):396-400.
  4. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the society of cardiovascular anesthesiologists. J Am Soc Echocardiogr. 2013;26(9):921-964.