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In addition to its role as an intraoperative diagnostic tool, transesophageal echocardiography (TEE) has been shown to be increasingly useful in the critical care setting. Patients in the critical care unit may have impaired cardiac function due to comorbidities or as a result of their critical illness. Indeed, cardiac dysfunction is one of the most common causes of hemodynamic instability and death in critically ill patients.1 Unlike many other diagnostic modalities available to the intensivist, TEE is minimally invasive and can be rapidly performed at the bedside. It can be used to provide valuable information on cardiac function, guide resuscitation and management, and diagnose a wide range of pathologies that may have a negative impact on the critically ill patient (Table 22–1). TEE was initially applied in the intensive care unit (ICU) for the postoperative evaluation of unstable cardiac surgery patients. However, TEE has also been shown to be beneficial in the general ICU setting, changing management in up to two-thirds of cases.2,3 In addition to the fact that the use of echocardiography has a positive impact on the management of patients in the general ICU,4 there is also evidence to support its therapeutic impact and its value in predicting mortality.5 Surprisingly, despite all these advantages, echocardiography is still not yet available in most ICUs, being largely limited by the availability of trained providers.5

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Table 22–1. TEE Diagnoses in the Hemodynamically Unstable Patient. 
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The indications for TEE, as previously discussed in this manual, also apply to critically ill patients. The ACC/ AHA/ASE guidelines define hemodynamic instability and suspected aortic dissection as class I indications for echocardiography in the ICU (ACC/AHA/ASE 2003 guidelines) (Table 22–2). Acutely ill trauma patients should also undergo an echocardiographic evaluation if they are suspected to have cardiac tamponade or aortic injury. The most common indication for which TEE is performed in the ICU is hemodynamic instability, followed by endocarditis, assessment of ventricular function, aortic pathology, and miscellaneous others.2

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Table 22–2. Recommendations for Echocardiography in the Critical Care Unit. 

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