Critical care echocardiography is increasingly recognized as an essential skill for intensivists to achieve during their training and fellowship. It serves to provide critical information to guide clinical management in patients with hemodynamic collapse and respiratory insufficiency. While transthoracic echocardiography (TTE) could be adequate for assessment in most situations, patient factors such as body habitus, presence of chest drains and tubes, presence of thoracic surgical dressings, requirement of high ventilatory support may impede operators from obtaining satisfactory images for evaluation. Moreover, operators in TTE require time and experience for adequate skill and technique acquisition. In specific pathologies such as infective endocarditis, presence of thrombus in left atrial appendage, and evaluation of intracardiac shunts, TEE has been shown to be superior to TTE for proper and accurate diagnosis. Therefore, TEE is widely accepted as the preferred and essential modality for echocardiographic examination especially in European countries. Countries such as France and North American have included critical care TEE as a core curriculum in the critical care training pathway.

In Hong Kong, only basic critical care echocardiography using TTE is required during training and in clinical practice. TEE evaluation is mostly performed in cardiac surgery units by cardiac anesthetists and in stable patients by cardiologists. Critical care TEE is seldom performed by intensivists independently for hemodynamic assessment and evaluation of cardiopulmonary failure. This study describes the safety, feasibility, and clinical utility of critical care TEE by critical care fellows in a university-affiliated institute providing tertiary care to the territory. With implementation of this essential technique in a single center, this study serves to act as a generalizable guidance to achieve an ultimate goal of incorporating this technique as core curriculum in critical care training in parts of the world where critical care TEE is not well established.

Inclusion Criteria:

• Age ≧ 18; AND
• Admitted to the mixed medical-surgical intensive care units of Queen Mary Hospital in Hong Kong; AND
• Intubated for invasive mechanical ventilation; AND
• Clinically indicated for transesophageal echocardiography (TEE)

Exclusion Criteria:

Patient possessing absolute contraindication(s) to TEE examination according to the ASE guideline 2013:

• Perforated viscus
• Esophageal stricture
• Esophageal tumor
• Esophageal perforation
• Esophageal laceration
• Esophageal diverticulum
• Active upper gastrointestinal bleed

Patients who suffer from cardiopulmonary failure requiring intubation and invasive mechanical ventilation, who benefit from detailed hemodynamic assessment by transesophageal echocardiography.