Transesophageal echocardiogram screening form

Transesophageal echocardiography is generally considered a safe and low risk procedure. As with all procedures there are some risks.

Oropharyngeal	Lip bruising/laceration, loose/chipped tooth, displaced dentures, pharyngeal laceration (injury to back of throat), perforation of the hypopharynx, accidental tracheal intubation (tube in wrong place)
Esophageal	Pain with swallowing, trouble swallowing, laceration/perforation, tear in esophagus (swallowing tube)
Gastric	Tear of stomach, bleeding
Miscellaneous	Splenic laceration, compression of mediastinal structures, airway compromise, thermal injury burn, tongue necrosis

Procedure

Your throat will be sprayed with a medicine to numb it.
IV (intravenous line) will be placed in your arm.
The technician then places small pads (electrodes) on your chest. The electrodes are attached by wires to a machine that will record your electrocardiogram (ECG) to track your heartbeat. A cannula will be placed in your nose and possibly a mask to give you oxygen.
The anesthesia provider will give a medication in your IV to put you to sleep
Then a thin, flexible tube (probe) is gently guided through your mouth and down your throat.
A transducer on the end of the probe sends sound waves to your heart and collects the echoes that bounce back.
These echoes become pictures that show up on a video screen.
When the TEE is complete, the probe, IV and electrodes are removed, and you will be monitored until you are fully awake. If do not have any other reason to stay, you can get dressed and leave when you are fully awake and able to eat

☐ Yes	☐ No	Problems swallowing
☐ Yes	☐ No	History of abnormality of your esophagus (swallowing tube) or stomach such as stricture (narrowing)
☐ Yes	☐ No	History of surgery involving your esophagus (swallowing tube)
☐ Yes	☐ No	History of radiation to your chest
☐ Yes	☐ No	History of cirrhosis or esophageal varices
☐ Yes	☐ No	Ulcer in your esophagus (swallowing tube) or stomach

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