Reported adverse effects of perioperative transesophageal echocardiography (TEE) are mostly associated with the insertion and manipulation of the TEE probe. In this case report of an anesthetized tracheally intubated patient undergoing cardiac surgery, we describe a novel technique wherein a soft-tipped esophageal bougie was used to facilitate insertion of the TEE probe. We believe this approach may potentially lead to less mechanical trauma when compared with the standard blind insertion technique. Written consent for publication of this case report was obtained from the patient.
A 65-year-old male patient presenting with symptomatic coronary artery disease was scheduled for coronary artery bypass grafting. There was no history of dysphagia, esophageal, or gastric disease. Examination of the airway revealed normal neck mobility with limited mouth opening, prominent incisors, and a large tongue.
After induction of anesthesia with propofol, fentanyl, and rocuronium, a Glidescope (Verathon Inc., Bothell, WA) was inserted with some difficulty due to limited mouth opening and the trachea intubated. In preparation for TEE probe insertion by an experienced echocardiographer, suctioning of the esophagus was performed via an orogastric tube placed easily with manual guidance into the hypopharynx. A TEE probe (ACUSON R V5M; Siemens Medical Solutions, Mountain View, CA) lubricated with ultrasound transmission gel was inserted into the oral cavity and carefully advanced in typical midline fashion posteriorly to the base of the tongue and the endotracheal tube (ETT). Despite manual jaw advancement and intraoral digital guidance of the TEE probe, resistance to insertion of the probe was encountered at an insertion depth of approximately 10 to 15 cm. The Glidescope was then used in an attempt to visualize the TEE probe but proved difficult due to the limited mouth opening with encroachment of the ETT and was removed. A 44 French esophageal bougie (Pillings Surgical Instruments, Research Triangle Park, NC) was then inserted into the oral cavity. The soft tip of the bougie easily passed the upper esophageal sphincter (UES), which appeared to be located slightly lateral from midline and was advanced without resistance to a depth of 35 cm into the esophagus, and then partially withdrawn and advanced to this depth several times. The bougie was then withdrawn to a depth of 15 cm so that only the tapered tip remained in the esophagus. The TEE probe was then reinserted into the oral cavity alongside the tapered tip of the bougie and advanced easily into midesophageal position while the bougie was completely removed (Fig. 1, Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A945). Surgery then commenced as planned, and the patient had an uneventful recovery with no evidence of dysphagia during the postoperative interview the following day.
TEE monitoring is widely used in cardiac and noncardiac procedures, and its perioperative use can be considered “appropriate” whenever severe hemodynamic, pulmonary, or neurologic compromise may be expected during a surgical case.1 Adverse effects are mostly associated with trauma of insertion and manipulation of the TEE probe, potentially involving any of the structures that the TEE probe needs to contact during the examination. The incidence of complications is similar to that of upper gastrointestinal (GI) endoscopy, with odynophagia and dysphagia most common.2 Yet, given varying definitions for symptom severity, there is likely variability in such morbidity. In a retrospective study of 7200 patients monitored with intraoperative TEE, Kallmeyer et al.3 reported 0.2% overall morbidity. However, only limited outcomes were assessed including odynophagia severe enough to warrant diagnostic esophagogastroduodenoscopy, clinically significant upper GI bleeding, dental damage, and dislodgement of the ETT. Conversely, in a recent randomized, prospective study comparing standard (blind insertion) versus assisted TEE probe placement (by rigid laryngoscope), more frequent oropharyngeal injury (55% vs 2%) and odynophagia (32.5% vs 2.5%) were noted in the standard group versus the assisted group, respectively.4 Also, in a prospective study of 869 cardiac surgery patients, Hogue et al.5 reported an increased risk for aspiration and pneumonia (odds ratio of 4.68) when TEE monitoring was used. That underreporting of oral or GI-related morbidity after TEE examination likely exists is supported by a prospective, randomized study comparing standard (blind insertion) with fiberoptic-assisted TEE probe placement.6 In this study, hypopharyngeal laceration was noted in 23.8% of the standard patient group versus 1.3% of the control group. Although the standard (blind) approach of TEE probe insertion may be associated with subclinical morbidity, the impact on overall patient outcome is not clear.
In anesthetized, tracheally intubated, and paralyzed patients, a TEE probe is typically inserted from the head of the bed with slight anteflexion of the probe. A bite block should not be placed in the mouth before placement of the probe in such patients because this maneuver will displace the tongue posteriorly and obstruct probe passage. Rather, it should be placed on the probe before insertion and then subsequently used. Conversely, use of a bite block during probe insertion is recommended in patients anesthetized without use of neuromuscular blocking drugs to prevent dental injury and damage of the equipment.7 Proper transpharyngeal passage into the esophagus is accomplished by observing midline passage posterior to the tongue (and posterior to the ETT when the trachea is intubated). The blind technique relies on haptic feedback when the TEE probe is advanced with varying degrees of resistance followed by a sudden release of resistance felt when the UES is passed. The UES is a high-pressure zone located between the hypopharynx and the esophagus, which poses the main physiologic barrier for successful TEE probe placement. It is located posteriorly to the cricoid cartilage, but it extends above and below it with a vertical length of 3 to 5 cm.8 Recent data suggest that the entry to the UES is not round but rather kidney shaped,9 a circumstance that could explain why the insertion of the TEE probe into the UES is often successful slightly lateral from midline. If the entry to the UES is missed, the probe can be malpositioned in the piriform fossae laterally10 or in the supraglottis anteriorly,11 potentially resulting in significant morbidity to hypopharyngeal structures.6 Additional barriers in the upper esophagus include Zenker’s diverticulum,12 and forceful advancement should be avoided when resistance is encountered even after successful passing of the UES.
This blind approach can be facilitated by insertion of the index and middle fingers of the opposite hand positioned behind the tongue to assist passage into the retropharynx. When the probe fails to advance, a variety of maneuvers have been recommended to facilitate probe insertion including changes of head position, manipulation of the thyroid cartilage, and jaw thrust. In addition, both direct laryngoscopy,4 video laryngoscopy,13 and fiberoptic assistance6 have been used successfully to aid in TEE insertion.
Esophageal dilation of chronic stenosis is a common indication for the use of a bougie (derived from the French word for a tapered wax candle); however, it is also used intraoperatively during general surgical procedures such as bariatric surgery and Nissen fundoplicaton.14,15 These devices come in several different configurations, some of which contain an inflatable balloon.16 Simple devices are differentiated in blunt-tipped (Hurst type) and tapered-tipped devices (Maloney type) formerly filled with mercury (Fig. 2).17 The bougie type used in this case was a simple, tapered, soft-tipped model made of silicone (Maloney type) internally stabilized with tungsten. Available diameters range from 10 to 50 French, and diameters in the range of 44 to 48 French correspond to those of an adult TEE probe. Although safety data for the use of esophageal bougies perioperatively are not available, their use during esophageal dilation procedures by GI interventionalists in high-risk patients is associated with a low risk of complications (<0.5% chance of perforation and 0.01% risk of death).16
We have used this novel technique in various situations successfully when entry into the UES was difficult with blind insertion and possibilities for visual guidance were limited. With proper care as described, the tapered, soft tip of the bougie is conceptually less traumatic and practically much easier to insert than a bluntly tipped, solid TEE probe (Fig. 3). Yet, mechanical injury along the path of insertion may still occur. It is also important to note that false passage remains a possibility due to the nonvisualized approach with this technique. Therefore, strict adherence to general safety principles of device insertion remains warranted.
Dr. Martin London is the Section Editor for Perioperative Echocardiography and Cardiovascular Education for Anesthesia & Analgesia. This manuscript was handled by Dr. Lawrence J. Saidman, Editor-in-Chief of A & A Case Reports, and Dr. London was not involved in any way with the editorial process or decision.
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