Transesophageal echocardiography probe cover: implementation of a cross-contamination containment strategy during the COVID-19 pandemic

Dear Editor,

In early 2020, in response to the COVID-19 pandemic, the American Society of Echocardiography released its Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak.¹ Shortly after, additional information was made available in the Perioperative/Periprocedural Transesophageal Echocardiography (TEE) Statement and the Sonographer Statement. These three statements contained multiple recommendations regarding patient selection and stratification, handwashing, droplet, and airborne precautions, limiting examination time and exposure of unnecessary equipment, and following recommended disinfection protocols.

Based on the statements and recommendations from other national medical organization guidelines including those from the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation, cardiologists at our institution adopted a screening process to more carefully select patients who truly require and will benefit from TEE evaluation. Cases deemed neither urgent nor emergent were postponed. Depending on personal protective equipment availability and preservation strategies, many hospitals implemented a heightened level of precaution in the care of all patients during the COVID-19 pandemic. At our institution, this included N-95 respirators (or powered air-purifying respirators) and gowns for the cardiologist, assisting circulating nurse, and anesthesia team for all patients requiring TEE – asymptomatic, under investigation, or COVID-19 positive. Additionally, technical precautions (e.g., avoiding deep sedation, rapid sequence induction for general anesthesia, avoidance of mask ventilation during induction, use of videolaryngoscopy for intubation, placement of barrier drapes during intubation, and the use of a TEE probe cover, etc.) were adopted. The American Society of Echocardiography later released a statement describing a similar tiered process to the selection of patients for TEE and the reintroduction of echocardiography services at each institution. This statement reaffirms the idea that the TEE examination is an aerosolizing procedure with airborne precautions recommended for COVID-19 positive or high-risk patients.² In the perioperative environment, the TEE probe is intermittently and frequently manipulated over a period of several hours during the surgical procedure, resulting in the possible contamination of multiple operating room surfaces. Several studies have demonstrated that anesthesiologists may be responsible for the possible spread of pathogens from the patient to the operating room environment, which may result in cross-contamination between providers and patients.^3,4

The technique utilized for covering each TEE probe at our institution is described below.

After inserting a clean TEE probe tip into the open end of a standard ultrasound probe cover and placing a rubber band above the wheel to secure the cover to the probe, we cut the opposite (closed) end of the probe cover with sterile scissors. We verify the cut portion of the probe cover is neat and tear-free, and then anchor it with a rubber band onto a bite block (Figure 1). The TEE probe is advanced beyond the bite block into the esophagus. The bite block is then positioned in the patient’s mouth. Because the exposed (contaminated) portion of the TEE probe remains within the probe cover, direct contact with secretions and potential for inadvertent spread to the operating room environment is minimized. As elective TEE cases have resumed, we have continued to use an ultrasound probe cover (Figure 1) as a protective barrier on each TEE probe and for many examinations.

Figure 1
Modified ultrasound probe cover used as a transesophageal echocardiography probe cover.

Although this method was developed independently at our institution, a similar method was proposed by Dr. Jain, an anesthesiologist from the Medical College of Georgia.⁵ We believe that this is a viable technique to both perform a high quality echocardiographic exam and to prevent exposure of the provider performing the TEE to oral secretions from the patient.

References

• ¹
  Kirkpatrick JN, Mitchell C, Taub C, et al. ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak: endorsed by the American College of Cardiology. J Am Soc Echocardiogr. 2020;33:648-53.
• ²
  Hung J, Abraham TP, Cohen MS, et al. ASE statement on the reintroduction of echocardiographic services during the COVID-19 pandemic. J Am Soc Echocardiogr. 2020;33:1034-9.
• ³
  Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology. 2008;109:399-407.
• ⁴
  Birnbach DJ, Rosen LF, Fitzpatrick M, et al. The use of a novel technology to study dynamics of pathogen transmission in the operating room. Anesth Analg. 2015;120:844-7.
• ⁵
  Jain A. Preventing contamination during transesophageal echocardiography in the face of the COVID-19 pandemic. J Cardiothorac Vasc Anesth. 2020;34:2849-51.

Publication Dates

• Publication in this collection
  24 May 2021
• Date of issue
  Mar-Apr 2021

History

• Received
  04 Sept 2020
• Accepted
  12 Dec 2021