Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.
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The American Society of Echocardiography designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
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The American Society of Echocardiography is committed to ensuring that its educational mission and all sponsored educational programs are not influenced by the special interests of any corporation or individual, and its mandate is to retain only those authors whose financial interests can be effectively resolved to maintain the goals and educational integrity of the activity. While a monetary or professional affiliation with a corporation does not necessarily influence an author’s presentation, the Essential Areas and policies of the ACCME require that any relationships that could possibly conflict with the educational value of the activity be resolved prior to publication and disclosed to the audience. Disclosures of faculty and commercial support relationships, if any, have been indicated.
Target Audience:
This activity is designed for all cardiovascular physicians and cardiac sonographers with a primary interest and knowledge base in the field of echocardiography; in addition, residents, researchers, clinicians, intensivists, and other medical professionals with a specific interest in cardiac ultrasound will find this activity beneficial.
Target Audience:
This activity is designed for all cardiovascular physicians and cardiac sonographers with a primary interest and knowledge base in the field of echocardiography; in addition, residents, researchers, clinicians, intensivists, and other medical professionals with a specific interest in cardiac ultrasound will find this activity beneficial.
Objectives:
Upon completing the reading of this article, the participants will better be able to:
- 1.
Recognize the different risk profile for TEE in the operative and non-operative setting.
- 2.
List the absolute and relative contraindications of TEE.
- 3.
Recognize the common sites and mechanisms of potential injury related to TEE in both the adult and pediatric populations.
- 4.
Appreciate the most common major and minor TEE-related injuries, including oropharyngeal, esophageal, and gastrointestinal injury.
- 5.
Apply recommendations for the prevention of TEE-related orogastric, cardiovascular, and respiratory complications, and appreciate the echocardiographic alternatives to TEE.
- 6.
Identify a subset of procedural risks more specific to the pediatric/infant population.
Disclosures:
Stanton K. Shernan, MD, FASE reported that he is on the speakers’ bureau for Philips Healthcare, Inc. All other authors of this article reported no actual or potential conflicts of interest in relation to the activity.
The ASE staff, ASE ACCME/CME Committee members and article reviewers who were involved in the planning and development of this activity reported no actual or potential conflicts of interest: Roger Click, MD, PhD; Chelsea Flowers; Rebecca T. Hahn, MD, FASE; Cathy Kerr; Donald Oxorn, MD; Priscilla P. Peters, BA, RDCS, FASE; and Cheryl Williams.
The following members of the JASE Editorial Staff reported no actual or potential conflicts of interest in relation to this activity: Julius M. Gardin, MD, FASE; Jonathan R. Lindner, MD, FASE; Victor Mor-Avi, PhD, FASE; Sherif Nagueh, MD, FASE; Alan S. Pearlman, MD, FASE; J. Geoffrey Stevenson, MD, FASE; and Alan D. Waggoner, MHS, RDCS.
Estimated Time to Complete This Activity: 1 hour
General Clinical Experience of Transesophageal Echocardiographic Safety
Reported rates of major TEE-related complications in ambulatory, nonoperative settings range from 0.2% to 0.5%. TEE-associated mortality has been estimated to be <0.01% ( Tables 2 and 3 ). These rates of adverse outcomes are comparable with those associated with gastroscopy or esophagogastroduodenoscopy (EGD), for which the overall risk for nonfatal complications is between 0.08% and 0.13%, and the reported mortality rate is approximately 0.004%. In comparison with the use of TEE in a nonoperative setting, intraoperative TEE poses a slightly different risk profile, because it involves probe placement and manipulation in intubated patients under general anesthesia who have frequently received neuromuscular blocking drugs. These patients are unable to swallow to facilitate probe insertion and cannot respond to possibly injurious probe manipulations. Furthermore, several consecutive transesophageal echocardiographic examinations or continuous intraoperative monitoring might be required for a subset of surgical patients. Overall rates of TEE-related morbidity with intraoperative TEE, however, have been estimated to be similar to nonoperative patients and range from 0.2% to 1.2%. In the largest study of intraoperative TEE–related complications to date, a single-center case series of 7,200 patients, Kallmeyer et al. reported TEE-associated morbidity and mortality of 0.2% and 0%, respectively. In contrast, Lennon et al. surveyed patients for later complications and suggested that rates of major gastrointestinal (GI) injuries (e.g., gastric laceration, hemorrhage, or perforation) could be as high as 1.2%. More than half of the complications presented >24 hours postoperatively, with one patient not presenting until day 11. The authors therefore suggested that the accurate assessment of overall risk for TEE may have previously been underestimated given a possible delay in the clinical manifestation of TEE-related GI injury.
| Complication | Ambulatory | Intraoperative | Pediatric | ICU |
|---|---|---|---|---|
| Dental injury | ASA/SCA 0.1% | Kallmeyer et al. 0.03% | ||
| Lip injuries | ASA/SCA 13% | |||
| Hoarseness | ASA/SCA 12% | |||
| Pharyngeal discomfort | Cyran et al. 5% | |||
| Severe odynophagia | Kallmeyer et al. 0.1% | |||
| Minor pharyngeal bleeding | Khandheria et al. 0.14%; Daniel et al. >0.01%; Seward et al. 0.2% | Kallmeyer et al. 0.01% | ||
| Dysphagia | ASA/SCA 1.8% | Hogue et al. (OR, 4.68); Rousou et al. (AO, 7.80); Owall et al. ∗ | ||
| Bronchospasm | Daniel et al. 0.07%; Chan et al. 0.06% | |||
| Laryngospasm | Seward et al. 0.14% | |||
| Endotracheal tube malposition | Kallmeyer et al. 0.03% | Stevenson 0.2% | ||
| Inadvertent tracheal extubation | Stevenson 0.5% | |||
| Tracheal intubation with probe | Chan et al. 0.02% | |||
| Airway obstruction | Stevenson 1%–5.5% | |||
| Compression-related complications | Greene et al. 0:50; Stevenson 0.6% | |||
| Dysrhythmias (AF, VF, VT, NSVT, AVB) | Daniel et al. 0.06%; Chan et al. 0.1%; Seward et al. 0.3% | Stevenson 0:1,650 | Slama et al. 1.6% | |
| CHF | Seward et al. 0.05% | |||
| Perforation | Daniel et al. <0.01% | Kallmeyer et al. 0.01%; Chan et al. 0:1,500; Lennon et al. 0.3% | ||
| Major bleeding | Daniel et al. <0.01% | Kallmeyer et al. 0.03%; Lennon et al. 0.8% | Stevenson 0:1,650 | |
| Mortality | Daniel et al. <0.01%; Khandheria et al. 0.02%; Seward et al. 0.01% | Kallmeyer et al. 0:7,600 | Stevenson 0:1,650 | Stoddard and Longaker 0:283 |
| Major morbidity | Seward et al. 0.2% | Kallmeyer et al. 0.2%; Lennon et al. 1.2%; Owall et al. 0:24 | Stoddard and Longaker <0.01% | |
| Overall complication rate | Daniel et al. 0.18%; Khandheria et al. 2.8% | Kallmeyer et al. 0.2% | Stevenson 2.4% | Khoury et al. 2.6%; Oh et al. 4%; Poelaert et al. 0:108 |
∗ No significant difference in the incidence of dysphagia between TEE and no TEE.
| Study | Population | Complications |
|---|---|---|
| Chan et al. | 1,700 ambulatory patients | Complication rate 0.47% (accidental tracheal intubation, bronchospasm, atrial fibrillation); placement failure 0.73% |
| Colreavy et al. | 255 critically ill patients | Complication rate 1.6%; transient hypotension, oropharyngeal bleeding, pulmonary aspiration |
| Daniel et al. | 10,419 conscious/sedated patients | Complication rate 0.18%; one mortality; placement failure 1.9% |
| Hogue et al. | 869 cardiac surgical patients | Risk for dysphagia independently correlated with intraoperative TEE, age, prolonged postoperative intubation |
| Hulyalkar and Ayd | Cardiac surgical patients | No increase in incidence of 41 prospectively studied postoperative frank or occult patients, 40 controls; 200 bleeding or gastroesophageal retrospectively studied complaints from controls |
| Kallmeyer et al. | 7,200 cardiac surgical patients | Morbidity 0.2%, no deaths |
| Khandheria et al. | 7,134 conscious/sedated patients | Complication rate 2.8%; major complications (laryngospasm, sustained ventricular tachycardia, congestive heart failure, death) 0.26%; one death |
| Lennon et al. | 516 cardiac surgical patients | Major gastroesophageal complications 1.2%, four gastroesophageal tears/ulcers, two gastric perforations, time of presentation < 11 days |
| Min et al. | 10,000 conscious/sedated patients | Mortality 0%; orogastric perforation 0.03% (one hypopharyngeal, two cervical esophageal, no gastric) |
| Owall et al. | 57 cardiac surgical patients | No increased rate of odynophagia, sore throat |
| Poelaert et al. | 108 critically ill patients | One transient ventricular tachycardia |
| Rousou et al. | 838 cardiac surgical patients | Odds ratio 7.8 dysphagia |
Risk of Transesophageal Echocardiography to the Oral Cavity, Pharynx, Esophagus, and Gastrointestinal Tract
Risk for Minor Oropharyngeal and Esophageal Injury
The overall incidence of TEE-related minor oropharyngeal injury, including lip trauma, dental injury, hoarseness, sore throat, dysphagia, or odynophagia, has been reported as 0.1% to 13%. In Kallmeyer et al. ’s series, dental injury occurred at a rate of 0.03%. Odynophagia severe enough to be investigated by EGD was reported in seven patients (0.1%). Endoscopic evaluation of these individuals revealed linear abrasions in the upper (one patient), middle (one patient), and lower esophagus (two patients). In a case series of 838 consecutive cardiac surgical patients by Rousou et al. , TEE was associated with an odds ratio for dysphagia 7.8 times greater than in patients in whom TEE was not performed. Although many of these events are frequently minor and self-limited, significant morbidity can result. In one study, dysphagia was associated with an increased incidence of aspiration, pneumonia, need for tracheostomy, and increased length of ICU stay. Hogue et al. reviewed the charts of 869 patients undergoing cardiac surgery (with and without TEE) and found that 4% subsequently had evaluation by barium swallow for swallowing dysfunction. Older age was the strongest independent predictor of swallowing dysfunction ( P < .001), followed by the duration of postoperative intubation ( P = .001), but the use of intraoperative TEE itself also appeared to be an independent risk factor for dysphagia (odds ratio, 4.68; 95% confidence interval, 1.76–12.43; P = .003).
Although an association between intraoperative TEE and postoperative dysphagia or odynophagia has been suggested, an independent correlation has not been consistently demonstrated. A prospective study by Owall et al. randomized 57 patients undergoing cardiac surgery to either have or not have transesophageal echocardiographic monitoring and reported no significant differences in the rates of sore throat or odynophagia. Another nonrandomized study prospectively examined 41 patients undergoing cardiac surgery with and 40 patients without TEE, as well as retrospective analysis of another 200 cases, and found no difference in anorexia, dysphagia, and sore throat. These studies are limited by size and/or lack of randomization. Given the morbidity that may be associated with severe dysphagia, further study of this area is warranted.
The incidence of dental injury ranges from 0.03% to 0.1% and correlates with a patient’s overall dental health. Dentures can also be dislodged by a TEE probe, highlighting a thorough preprocedural assessment of the oral cavity. Sriram et al. reported a case of tongue necrosis and formation of a permanent cleft associated with TEE probe position in a prolonged cardiac operation. Intraoperative tongue swelling in the setting of TEE has been described in the past, but the majority of tongue pathology in the perioperative period is attributed to endotracheal tube position, the duration of endotracheal intubation, or the surgical procedure itself (i.e., head and neck surgery, prone positioning, and risk for venous congestion).
TEE and Orogastric Tract Perforation
Upper GI perforations after TEE have been reported in both pediatric and adult surgical patients, with an estimated incidence between 0.01% and 0.04%. This incidence is consistent with the approximate rate of one to three per 10,000 TEE-related perforations in ambulatory, conscious, or semiconscious patients. GI perforation is associated with severe morbidity, and depending on mode of management (surgical vs medical) and time to diagnosis, mortality can range from 10% to 56%. Delayed recognition of serious orogastric canal injury or perforation can be a problem in heavily sedated patients and in the setting of intraoperative TEE in anesthetized patients. Although evidence of rupture may be dramatic with the sudden appearance of the probe in the surgical field, excessive orogastric hemorrhage, or subcutaneous emphysema, the signs of perforation are frequently subtle and likely to be masked by sedation or general anesthesia and postoperative intubation and sedation. Patients may present much later with nonspecific signs such as dyspnea, agitation, fever, or bloody nasogastric aspirates. Symptoms relating to spontaneous esophageal perforation such as Meckler’s triad of vomiting, pain, and subcutaneous emphysema are rarely present, and according to one study of esophageal perforation from all causes, up to 33% of initial chest radiographs are within normal limits. A high level of vigilance for the potential for esophageal rupture must be maintained when considering the etiology of immediate postoperative findings such as pneumothorax, pleural effusions, or postprocedural shortness of breath.
Certain areas of the orogastric tract appear to be more susceptible to perforation than others. One review of EGD reported that ruptures occurred in the hypopharynx 20% of the time, the esophagus 40%, the stomach 5%, and the duodenum 35%. During TEE probe placement, the parapharyngeal area may be vulnerable to injury if the probe gets lodged in one of the pyriform sinuses ( Figures 2 A and 2 B). The upper esophagus at the level of the cricopharynx may also be particularly prone to injury, because the posterior aspect of the esophagus at the Lannier triangle, is covered only by fascia. Spasm or hypertrophy of the cricopharyngeal muscle or narrowing of the space by osteophytic disease of the cervical spinal column may further increase risk for tissue disruption or perforation ( Figure 1 ). In a recent, large single-center series of 10,000 consecutive transesophageal echocardiographic exams in ambulatory patients, Min et al. reported three cases (0.03%) of TEE-associated perforation: one hypopharyngeal and two cervical esophageal. The authors noted that each case was associated with difficult probe placement and advanced patient age (>75 years).
An increased risk for perforation is associated with TEE in patients with gastroesophageal pathology (e.g., Zenker’s diverticulum, esophageal stricture or obstructing mass, fibrosis secondary to prior chest radiation), distorted anatomy (e.g., massive cardiomegaly, tracheoesophageal fistula or atresia), and resistance to probe insertion ( Table 4 ). However, perforations have also been documented in patients with no previous GI disease. One case report of a gastroesophageal junction perforation in an elderly patient with severe peripheral vascular disease undergoing revascularization of the lower extremity suggests that rupture could occur secondary to compression of ischemia prone tissues. Some authors have speculated that factors such as small stature, older age, chronic steroid use, prolonged procedure time, history of radiation therapy involving the thorax, presence of congestive heart failure, and low cardiac output before and after cardiopulmonary bypass may be correlated with increased risk for perforation or serious GI injury.
| Absolute Contraindications | Relative Contraindications |
|---|---|
| Perforated viscous | Atlantoaxial joint disease ∗ |
| Esophageal pathology (stricture, trauma, tumor, scleroderma, Mallory-Weiss tear, diverticulum) † | Severe cervical arthritis ∗ |
| Active upper GI bleeding | Prior radiation to the chest |
| Recent upper GI surgery | Symptomatic hiatal hernia |
| Esophagectomy, esophagogastrectomy | History of GI surgery |
| Recent upper GI bleed | |
| Esophagitis, peptic ulcer disease | |
| Thoracoabdominal aneurysm | |
| Barrett’s esophagus | |
| History of dysphagia | |
| Coagulopathy, thrombocytopenia |
∗ Causing restricted cervical mobility.
† TEE may be used for patients with oral, esophageal, or gastric disease, if the expected benefit outweighs the potential risk, provided the appropriate precautions are applied. These precautions may include the following: considering other imaging modalities (e.g., epicardial echocardiography), obtaining a gastroenterology consultation, limiting the examination, avoiding unnecessary probe manipulation, and using the most experienced operator.
TEE-Related GI Bleeding
GI trauma associated with TEE can, in rare instances, lead to serious bleeding. At least 13 cases of major upper GI hemorrhage have been reported in the literature to date. Such episodes have involved large-volume hematemesis or orogastric aspirates of copious bright red blood or “coffee grounds” from 500 mL to as much as 9 L throughout the postoperative period. The overall incidence of major bleeding complications after TEE has been estimated to be between 0.02% and 1.0%.
GI bleeding is often secondary to direct trauma to the mucosa or mechanical disruption of friable tissues (e.g., esophageal varices, esophageal tumor). Other non-GI bleeding, such as cardiac tamponade from rupture of an aortic aneurysm, rupture of an aortic dissection, and splenic laceration during intraoperative TEE, have also been described. In a large case series of ambulatory (nonoperative), conscious transesophageal echocardiographic exams by Daniel et al. , fatal hemorrhage occurred in one patient in whom TEE probe insertion disrupted esophageal tissue infiltrated by a lung tumor. Minor pharyngeal bleeding occurred in 0.01% (one of 10,218) of the examinations and can lead to aspiration in patients unable to protect their airways.
Given the potential for TEE to cause injury to the orogastric mucosa, there is a recognized risk for GI bleeding after intraoperative TEE during cardiac surgery, particularly given anticoagulation and post cardiopulmonary bypass coagulopathies. St-Pierre et al. reported a case of massive hemorrhage after TEE in a patient undergoing coronary bypass grafting following an acute myocardial infarction. The patient was fully heparinized for cardiopulmonary bypass when the TEE probe was inserted and the echocardiographic exam was performed. Immediately after removal of the probe, 1.2 L of bright red blood drained from the orogastric tube. Subsequent EGD showed evidence of a mucosal tear near the gastroesophageal junction, as well as multiple erosions noted within the esophagus. In another case report, an 81-year-old woman undergoing aortic and mitral valve repair and coronary artery bypass surgery developed upper GI bleeding with almost 1 L of bright red blood aspirated by the orogastric tube. EGD showed several linear abrasions in the esophagus and a large contusion and mucosal tear at the gastroesophageal junction.
Despite these and other reports, multiple studies have failed to show an increased risk for GI bleeding after TEE, even in the setting of anticoagulation. In fact, cardiac surgery itself is associated with upper GI bleeding, often secondary to bleeding duodenal ulcers or gastric erosions. In a case series of 8,559 patients undergoing cardiac surgery with cardiopulmonary bypass and no TEE, Egleston et al. reported gastric complications in 0.41% of patients and an associated mortality rate of 25.7%. Thus, many GI injuries may not be due to TEE. Hulyalkar and Ayd evaluated 41 patients undergoing cardiac surgery with TEE matched with 40 cardiac surgical patient controls in whom TEE was not performed. A retrospective analysis of additional 200 randomly selected patients was also performed. The investigators reported no difference between the control and TEE (prospective and retrospective) groups in the incidence of occult blood in nasogastric tube aspirates. Similarly, McSweeney et al. examined risk factors for GI complications in patients undergoing cardiac surgery and reported that although the overall incidence of complications in patients undergoing intraoperative TEE was increased, TEE was not an independent predictor of major GI morbidity.
Although anticoagulation does not appear to greatly increase the risk for TEE-associated bleeding complications, procedures such as thrombolysis may increase the potential for subsequent bleeding after TEE. One large study reported severe hemorrhage with a hemothorax and shock after rupture of a large intramural hematoma of the esophagus in a patient who underwent thrombolysis for a partially thrombosed prosthetic mitral valve 4 hours after diagnostic TEE. Given the potential for bleeding complications, placing TEE probes before full anticoagulation is generally advised.
Another presumed relative contraindication to TEE is the presence of esophageal varices (e.g., in liver transplantation patients). The concern for injury related to esophageal manipulation stems largely from case reports depicting complications from nasogastric tube or esophageal stethoscope placement in this patient population. The guidelines on the prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis by the American College of Gastroenterology recommend endoscopic surveillance for gastroesophageal varices in patients with established diagnoses of cirrhosis. In a recently published retrospective case series in patients with known varices, Spier et al. highlighted the relative safety of TEE. The authors concluded that adherence to the published American College of Gastroenterology surveillance guidelines seems safe practice in cirrhotic patients but recommend a preprocedural endoscopy for patients who have not previously been evaluated. To date, there are no reports of procedure-related complications of TEE in a patient with varices, suggesting that TEE can be performed without excessive risk in this patient population.
Miscellaneous Risks of Transesophageal Echocardiography
Cardiovascular and Respiratory Complications
Reports of cardiovascular complications following TEE (e.g., associated arrhythmias) are rare. In a series of 341 obese patients and 323 control patients undergoing TEE, there was one case of atrial fibrillation in the obese group and one case of supraventricular tachycardia in the control group associated with the procedure. Another study of 10,419 patients, of whom 88.7% were conscious and the vast majority without sedation, found three cases of nonsustained ventricular tachycardia, three cases of transient atrial fibrillation, and one case of third-degree atrioventricular block. More literature exists on cardiovascular complications of upper GI endoscopy. In 21,946 endoscopic procedures performed over a 4-year period, there were four cases of supraventricular tachycardia, two cases of myocardial infarction, and one case of congestive heart failure. Tseng et al. found ventricular arrhythmias and myocardial ischemia, although mostly subclinical, to be common in patients with stable coronary artery disease undergoing emergent endoscopy for upper GI bleeds, especially in those with concomitant congestive heart failure. The growing use of TEE has led to a larger number of examinations in increasingly ill patients. Patients with cardiomyopathies potentially have a higher propensity for arrhythmias. It is therefore conceivable that the release of adrenergic hormones and possible hypoxemia and hypercarbia from procedural sedation could act as triggers for arrhythmias.
Respiratory complications associated with TEE have also been described. Intraoperative TEE–related endotracheal tube malpositioning was noted in 0.03% of cases in Kallmeyer et al. ’s study and can potentially lead to catastrophic outcomes. However, respiratory compromise primarily occurs in the nonoperative setting and includes hypoxia, unplanned need for endotracheal intubation (secondary to oversedation or aspiration), accidental tracheal intubation with the probe, bronchospasm, and laryngospasm. Methemoglobinemia and ensuing hypoxemia from topicalization of the oropharynx with benzocaine in preparation for TEE probe insertion has also been reported. Airway compression is more common in the pediatric population, but has been found in adults as well. Arima et al. reported airway obstruction during TEE probe placement in a patient with tracheal distortion from an ascending aortic pseudoaneurysm. Recurrent laryngeal nerve injury has been encountered, particularly in the setting of transesophageal echocardiographic monitoring during neurosurgical procedures with patients in the sitting position. In cardiac surgery, however, Kawahito et al. followed 116 patients (64 patients with TEE and 52 patients with no TEE) and did not find a statistically significant difference in the incidence of recurrent laryngeal nerve injury.
Thermal Injury, Infectious, and Chemical Complications
Thermal tissue injury created by the piezoelectric crystal vibration within the probe tip or by direct absorption of ultrasound energy has also been proposed as a potential mechanism of injury. Although animal studies have not demonstrated any histopathologic changes attributable to ultrasound energy in this setting, thermal injury has been suspected in the setting of patients with severe atherosclerosis and possibly poorly vascularized and friable esophageal tissue. Although the risk for thermal injury seems to be minimal, measures can be taken to limit the risk for thermal or necrotic damage to the esophageal mucosa. The probe may be set at the minimal gain and acoustic power necessary to obtain adequate images. In addition, the power can be turned off during cardiopulmonary bypass, while the probe tip should be kept in an unlocked, unflexed position when not being used. To address the issue of inadvertent heating of the probe, most probes are fitted with a thermistor to sense increases in temperature and are designed to automatically shut down if a preset threshold temperature (42°C–44°C) is reached.
The Association for Professionals in Infection Control and Epidemiology has published guidelines for infection prevention and control in flexible endoscopy. Current standard high-level disinfection practices use a multistep process that relies on liquid chemical sterilants followed by a rinsing step with water. The use of aldehyde and nonaldehyde sterilization solutions has decreased endoscopy-related infection rates but carries the risk for chemical burns in case of insufficient water rinse. Moreover, infectious complications (i.e., Legionella pneumophila ) have been linked to contaminated rinse water.
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