Newly Published Free
Correspondence  |   May 2020
Transesophageal Echocardiography Probe Sheath to Decrease Provider and Environment Contamination
Author Notes
  • University of Nebraska Medical Center, Omaha, Nebraska (N.W.M.). nmarkin@unmc.edu
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • (Accepted for publication April 21, 2020.)
    (Accepted for publication April 21, 2020.)×
Article Information
Correspondence
Correspondence   |   May 2020
Transesophageal Echocardiography Probe Sheath to Decrease Provider and Environment Contamination
Anesthesiology Newly Published on May 6, 2020. doi:https://doi.org/10.1097/ALN.0000000000003370
Anesthesiology Newly Published on May 6, 2020. doi:https://doi.org/10.1097/ALN.0000000000003370
To the Editor:
The 2019 novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) and its associated disease, coronavirus disease 2019 (COVID-19), have resulted in a global pandemic and caused significant morbidity and mortality.1  The American Society of Echocardiography (Durham, North Carolina) released a statement adjudicating the use of personal protective equipment for all echocardiographic procedures. Special attention was given for transesophageal echocardiograms (TEE) which “carry a heightened risk of spread of the SARS-CoV-2 since they can provoke aerosolization of a large amount of virus.”2,3  The concern for potential aerosolization and provider contamination during the performance of TEE has led our institution to define all TEEs, even in the presence of an endotracheal tube managed airway, as an aerosol-generating procedure. This is in part because of the risk of small particle generation occurring during the procedure but also because of concerns over cross contamination of the probe, operator, echo machine, and surrounding surfaces with oropharyngeal secretions which are known to contain the virus.4  As such, full COVID-19 personal protective equipment consisting of an N95 respirator, face shield, gown, and two layers of gloves was mandated for all staff involved in the performance of TEE.
To reduce the risk of both aerosolization and provider/environmental contamination, we devised a sheathing system using two preexisting commercially available products seen in figure 1A. As demonstrated in figure 1B, a CIV-Flex 8.9 cm × 91.5 cm Transducer Cover (CIVCO, USA) probe cover is combined with a Blox 54 FR Endoscopic Bite Block (EndoChoice, Inc., USA) to create a freely sliding barrier which still allows the imager to position the TEE probe normally, then engage the bite block to the patient’s mouth and secure it around the head with the included elastic strap. Note that the distal end of the sheathing system is open to allow the probe to advance past the bite block with one of the included rubber bands holding the components together (fig. 1C) and the proximal extent of the sheath extending to the 1-meter mark (fig. 1D). The second rubber band is folded three times and secured around the proximal end of the sheath to keep it from moving. Step-by-step assembly instructions are demonstrated in Supplemental Digital Content, video 1 (http://links.lww.com/ALN/C390). This way, the combination of a secured airway via an endotracheal tube and a fully enclosed TEE sheath, we have converted our TEE procedure categorization from a high-risk aerosol-generating procedure to a low-risk procedure, removing the need for use of N95 masks. This simple and easily generalizable modification preserves scarce personal protective equipment resources5  and reduces the risk of contamination by the provider to oneself or the environment.
Fig. 1.
(A) Transesophageal echocardiogram probe clean sheath assembled. (B) Required components for the assembly of the sheath: bite block, probe cover with rubber bands, and scissors. (C) Detail of the distal end of the sheath demonstrating the probe cover and rubber band arrangement. (D) Detail of the proximal end showing the rubber band holding the cover to the probe near the 1 meter mark.
(A) Transesophageal echocardiogram probe clean sheath assembled. (B) Required components for the assembly of the sheath: bite block, probe cover with rubber bands, and scissors. (C) Detail of the distal end of the sheath demonstrating the probe cover and rubber band arrangement. (D) Detail of the proximal end showing the rubber band holding the cover to the probe near the 1 meter mark.
Fig. 1.
(A) Transesophageal echocardiogram probe clean sheath assembled. (B) Required components for the assembly of the sheath: bite block, probe cover with rubber bands, and scissors. (C) Detail of the distal end of the sheath demonstrating the probe cover and rubber band arrangement. (D) Detail of the proximal end showing the rubber band holding the cover to the probe near the 1 meter mark.
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Although use of a TEE probe cover has been previously described,6  it does not eliminate contamination when the cover is moved within the oropharynx and the esophagus. The sheath design herein described maintains a noncontaminated surface for the echocardiographer to grasp when manipulating the TEE probe. In addition to mitigating the risk that SARS-CoV-2 poses to both patients and providers, we believe that this inexpensive adjustment to practice will reduce both unnecessary personal protective equipment usage and risk for contamination.
Research Support
Support was provided solely from institutional and/or departmental sources.
Competing Interests
Dr. Cawcutt was paid an honorarium for the creation of educational materials by the Society of Healthcare Epidemiology of America (Arlington, Virginia) and is a paid medical writer for The Clorox Company (Oakland, California). The other authors declare no competing interests.
References
World Health Organization, Regional Office for Europe, WHO announces COVID-19 outbreak a pandemic. Available at: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/3/who-announces-covid-19-outbreak-a-pandemic. Accessed April 3, 2020.
Kirkpatrick, JN, Mitchell, C, Taub, C, Kort, S, Hung, J, Swaminathan, M. ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak J Am Coll Cardiol 2020 doi: https://doi.org/10.1016/j.jacc.2020.04.002
Nicoara, A, Maldonado, Y, Kort, S, Swaminathan, M, Mackensen, G. Specific considerations for the protection of patients and echocardiography service providers when performing perioperative or periprocedural transesophageal echocardiography during the 2019 novel coronavirus outbreak: Council on Perioperative Echocardiography Supplement to the Statement of the American Society of Echocardiography. Available at: https://www.asecho.org/wp-content/uploads/2020/04/COPE_COVID_Supplement_FINAL.pdf. Accessed April 17, 2020.
Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19). 2020 China, World Health Organization 1–40
World Health Organization, Shortage of personal protective equipment endangering health worker worldwide. Available at: https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide. Accessed April 3, 2020.
Fritz, S, Hust, MH, Ochs, C, Gratwohl, I, Staiger, M, Braun, B . Use of a latex cover sheath for transesophageal echocardiography (TEE) instead of regular disinfection of the echoscope? Clin Cardiol 1993; 16:737–40 [Article] [PubMed]
Fig. 1.
(A) Transesophageal echocardiogram probe clean sheath assembled. (B) Required components for the assembly of the sheath: bite block, probe cover with rubber bands, and scissors. (C) Detail of the distal end of the sheath demonstrating the probe cover and rubber band arrangement. (D) Detail of the proximal end showing the rubber band holding the cover to the probe near the 1 meter mark.
(A) Transesophageal echocardiogram probe clean sheath assembled. (B) Required components for the assembly of the sheath: bite block, probe cover with rubber bands, and scissors. (C) Detail of the distal end of the sheath demonstrating the probe cover and rubber band arrangement. (D) Detail of the proximal end showing the rubber band holding the cover to the probe near the 1 meter mark.
Fig. 1.
(A) Transesophageal echocardiogram probe clean sheath assembled. (B) Required components for the assembly of the sheath: bite block, probe cover with rubber bands, and scissors. (C) Detail of the distal end of the sheath demonstrating the probe cover and rubber band arrangement. (D) Detail of the proximal end showing the rubber band holding the cover to the probe near the 1 meter mark.
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