Title: Iatrogenic Oropharyngeal Injury and Hemorrhage Requiring Blood Transfusions During Insertion of Transesophageal Echocardiographic Probes in Patients Undergoing Cardiac Surgery
Abstract: Complications such as oromucosal injury, perforation of the esophagus, perforation of the stomach, and death have been attributed to the insertion of a transesophageal echocardiography (TEE) probe.1Kallmeyer I.J. Collard C.D. Fox J.A. et al.The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients.Anesth Analg. 2001; 92: 1126-1130Crossref PubMed Scopus (354) Google Scholar, 2Huang C.H. Lu C.W. Lin T.Y. et al.Complications of intraoperative transesophageal echocardiography in adult cardiac surgical patients—Experience of two institutions in Taiwan.J Formos Med Assoc. 2007; 106: 92-95Abstract Full Text PDF PubMed Scopus (27) Google Scholar, 3Lennon M.J. Gibbs N.M. Weightman W.M. et al.Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients.J Cardiothorac Vasc Anesth. 2005; 19: 141-145Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar However, after an audit of 7,200 patients, it was suggested that TEE is a safe mode of investigation.1Kallmeyer I.J. Collard C.D. Fox J.A. et al.The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients.Anesth Analg. 2001; 92: 1126-1130Crossref PubMed Scopus (354) Google Scholar Additionally, intraoperative TEE influenced cardiac surgical decisions in more than 9% of 12,000 patients, with the greatest observed impact in patients undergoing combined coronary artery bypass graft surgery and valve procedures.4Eltzschig H.K. Rosenberger P. Löffler M. et al.Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery.Ann Thorac Surg. 2008; 85: 845-852Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar Based on the reported morbidities and mortalities associated with the use of a TEE probe, it is difficult to make an observation on the risk-benefit analysis of intraoperative TEE. Despite these claimed unquestionable benefits, Piercy et al5Piercy M. McNicol L. Dinh D.T. et al.Major complications related to the use of transesophageal echocardiography in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 62-65Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar recently recommended that “TEE use in cardiac surgery should be evaluated in the light of practice guidelines and morbidity and mortality data and not considered routine” after encountering 3 deaths among other morbidities in their analysis of data collected over 2 years. It is now clear that despite several claimed benefits, caution has to be exercised when a TEE probe is inserted. We report 2 cases of iatrogenic oropharyngeal injury after TEE probe insertion. Unanticipated difficulty was encountered in intubation of the first patient who developed hemorrhage requiring otolaryngologic intervention and blood transfusion. The second patient required insertion of a TEE probe with compromised exposure to the oral cavity (caused by the metal frame used routinely at our center) after the induction of general anesthesia and the commencement of surgery. The probe was maneuvered under the metal frame. The TEE probe caused injury to the posterior pharyngeal wall, resulting in hemorrhage requiring blood transfusion.A diabetic patient, aged 64 years, weighing 65 kg, without other comorbidities, presented for elective coronary artery bypass graft surgery. Preoperative laboratory tests did not reveal any problems. On the day of surgery, after the insertion of monitoring catheters in the operating room, general anesthesia was induced with 2% to 3% of inhaled sevoflurane. Orotracheal intubation was facilitated by intravenous administration of 75 mg of rocuronium. During laryngoscopy, the larynx was found to be anterior; the vocal cords could not be visualized. The orotracheal tube could be passed with difficulty into the trachea after the trachea was pushed posteriorly by an assistant. After intubation, the oral cavity was checked for injuries because the insertion of a TEE probe was contemplated; none was found. Difficulty was encountered in passing the TEE probe despite lubricating it well with lidocaine jelly. After several attempts, a senior anesthesiologist inserted the probe while the mandible was pulled up by an assistant. Blood-tinged saliva was found in the oral cavity after completion of the TEE probe insertion. It seemed to settle after suctioning the oral cavity. The surgery commenced via a midsternotomy. After heparinization with 20,000 U of intravenous heparin, blood was seen to ooze from the mouth. Oral secretions were suctioned from the oral cavity repeatedly. It was decided to wait for the completion of surgery and the reversal of residual heparin with intravenous protamine to check for the source of the bleeder. Off-pump coronary artery bypass surgery was completed; the intraoperative blood loss estimated by gravimetric method was 350 mL. After completion of the surgery and reversal of residual heparin, a laryngoscopic examination revealed blood clots in the oral cavity. After clearing the oral cavity, it was found that the right posterior pillar of the tonsil was traumatized during repeated attempts at insertion of the TEE probe. An otolaryngologic consult was requested; after examination of the oral cavity, the otolaryngologic surgeon suggested ligation of the bleeder and cauterization of the abraded parts of the right tonsil. The patient's hemoglobin was 6 g/dL; it returned to 9 g/dL after the transfusion of 3 U of packed red cells.The second case was a moderately obese 68-year-old woman weighing 102 kg scheduled to undergo elective coronary artery bypass graft surgery and mitral valve replacement. Apart from obesity, well-controlled hypertension, and diabetes mellitus (controlled well with preoperative hypoglycemic agents), the patient had no problems. After the routine induction of general anesthesia and orotracheal intubation, the patient was positioned as per institutional protocol, which included placing a metal frame over the head of the operating table (Fig 1). This frame has been used for the past 2 decades by our surgeons to temporarily store important surgical equipment on it during surgery; this enables them to pick up the instruments without having to wait for the scrub nurse to hand them over. After commencing the surgery, the surgeon wanted the insertion of a TEE probe because he thought that the patient might need a mitral valve repair. The TEE probe was maneuvered under the metal frame with difficulty and was passed into the esophagus. The patient underwent coronary artery bypass and mitral valve repair. While the surgery was underway, we noted blood-stained saliva oozing out of the mouth. The intraoperative blood loss assessed by gravimetric method was 350 mL. After completion of the surgery, when unhindered access to the oral cavity was gained, it was visualized using a laryngoscope. The posterior pharyngeal wall had an abrasion most likely caused during TEE probe insertion. The ooze from the abraded pharynx could be stopped by coagulating the bleeder using bipolar diathermy. An approximate estimate of blood loss from the oropharynx was 750 mL (assessed using the gravimetric method). The oral cavity was suctioned continuously using a suction catheter placed in the oral cavity. The patient required 4 U of packed red cells and 6 U of fresh frozen plasma to counter the hemorrhage caused by surgery and the pharyngeal trauma.Although trauma during the insertion of a TEE probe has been reported, the circumstances under which the oropharyngeal trauma occurred in these cases were different. Because of these 2 cases, we now insert the TEE probe under direct vision whenever difficulty in endotracheal intubation is encountered. It is logical to expect the anatomic variation of the airway that causes difficulty in endotracheal intubation will also produce difficult conditions for the insertion of the TEE probe. If access to the oral cavity is not available with an unhindered view of the airway, the TEE probe should not be inserted. We agree with Piercy et al about reconsidering the use of TEE monitoring after careful consideration in each case. One must reconsider the decision to insert a TEE probe when encountering conditions causing difficult intubation or abnormal patient position at the time of probe insertion or compromised accessibility of the oral cavity. Complications such as oromucosal injury, perforation of the esophagus, perforation of the stomach, and death have been attributed to the insertion of a transesophageal echocardiography (TEE) probe.1Kallmeyer I.J. Collard C.D. Fox J.A. et al.The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients.Anesth Analg. 2001; 92: 1126-1130Crossref PubMed Scopus (354) Google Scholar, 2Huang C.H. Lu C.W. Lin T.Y. et al.Complications of intraoperative transesophageal echocardiography in adult cardiac surgical patients—Experience of two institutions in Taiwan.J Formos Med Assoc. 2007; 106: 92-95Abstract Full Text PDF PubMed Scopus (27) Google Scholar, 3Lennon M.J. Gibbs N.M. Weightman W.M. et al.Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients.J Cardiothorac Vasc Anesth. 2005; 19: 141-145Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar However, after an audit of 7,200 patients, it was suggested that TEE is a safe mode of investigation.1Kallmeyer I.J. Collard C.D. Fox J.A. et al.The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients.Anesth Analg. 2001; 92: 1126-1130Crossref PubMed Scopus (354) Google Scholar Additionally, intraoperative TEE influenced cardiac surgical decisions in more than 9% of 12,000 patients, with the greatest observed impact in patients undergoing combined coronary artery bypass graft surgery and valve procedures.4Eltzschig H.K. Rosenberger P. Löffler M. et al.Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery.Ann Thorac Surg. 2008; 85: 845-852Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar Based on the reported morbidities and mortalities associated with the use of a TEE probe, it is difficult to make an observation on the risk-benefit analysis of intraoperative TEE. Despite these claimed unquestionable benefits, Piercy et al5Piercy M. McNicol L. Dinh D.T. et al.Major complications related to the use of transesophageal echocardiography in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 62-65Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar recently recommended that “TEE use in cardiac surgery should be evaluated in the light of practice guidelines and morbidity and mortality data and not considered routine” after encountering 3 deaths among other morbidities in their analysis of data collected over 2 years. It is now clear that despite several claimed benefits, caution has to be exercised when a TEE probe is inserted. We report 2 cases of iatrogenic oropharyngeal injury after TEE probe insertion. Unanticipated difficulty was encountered in intubation of the first patient who developed hemorrhage requiring otolaryngologic intervention and blood transfusion. The second patient required insertion of a TEE probe with compromised exposure to the oral cavity (caused by the metal frame used routinely at our center) after the induction of general anesthesia and the commencement of surgery. The probe was maneuvered under the metal frame. The TEE probe caused injury to the posterior pharyngeal wall, resulting in hemorrhage requiring blood transfusion. A diabetic patient, aged 64 years, weighing 65 kg, without other comorbidities, presented for elective coronary artery bypass graft surgery. Preoperative laboratory tests did not reveal any problems. On the day of surgery, after the insertion of monitoring catheters in the operating room, general anesthesia was induced with 2% to 3% of inhaled sevoflurane. Orotracheal intubation was facilitated by intravenous administration of 75 mg of rocuronium. During laryngoscopy, the larynx was found to be anterior; the vocal cords could not be visualized. The orotracheal tube could be passed with difficulty into the trachea after the trachea was pushed posteriorly by an assistant. After intubation, the oral cavity was checked for injuries because the insertion of a TEE probe was contemplated; none was found. Difficulty was encountered in passing the TEE probe despite lubricating it well with lidocaine jelly. After several attempts, a senior anesthesiologist inserted the probe while the mandible was pulled up by an assistant. Blood-tinged saliva was found in the oral cavity after completion of the TEE probe insertion. It seemed to settle after suctioning the oral cavity. The surgery commenced via a midsternotomy. After heparinization with 20,000 U of intravenous heparin, blood was seen to ooze from the mouth. Oral secretions were suctioned from the oral cavity repeatedly. It was decided to wait for the completion of surgery and the reversal of residual heparin with intravenous protamine to check for the source of the bleeder. Off-pump coronary artery bypass surgery was completed; the intraoperative blood loss estimated by gravimetric method was 350 mL. After completion of the surgery and reversal of residual heparin, a laryngoscopic examination revealed blood clots in the oral cavity. After clearing the oral cavity, it was found that the right posterior pillar of the tonsil was traumatized during repeated attempts at insertion of the TEE probe. An otolaryngologic consult was requested; after examination of the oral cavity, the otolaryngologic surgeon suggested ligation of the bleeder and cauterization of the abraded parts of the right tonsil. The patient's hemoglobin was 6 g/dL; it returned to 9 g/dL after the transfusion of 3 U of packed red cells. The second case was a moderately obese 68-year-old woman weighing 102 kg scheduled to undergo elective coronary artery bypass graft surgery and mitral valve replacement. Apart from obesity, well-controlled hypertension, and diabetes mellitus (controlled well with preoperative hypoglycemic agents), the patient had no problems. After the routine induction of general anesthesia and orotracheal intubation, the patient was positioned as per institutional protocol, which included placing a metal frame over the head of the operating table (Fig 1). This frame has been used for the past 2 decades by our surgeons to temporarily store important surgical equipment on it during surgery; this enables them to pick up the instruments without having to wait for the scrub nurse to hand them over. After commencing the surgery, the surgeon wanted the insertion of a TEE probe because he thought that the patient might need a mitral valve repair. The TEE probe was maneuvered under the metal frame with difficulty and was passed into the esophagus. The patient underwent coronary artery bypass and mitral valve repair. While the surgery was underway, we noted blood-stained saliva oozing out of the mouth. The intraoperative blood loss assessed by gravimetric method was 350 mL. After completion of the surgery, when unhindered access to the oral cavity was gained, it was visualized using a laryngoscope. The posterior pharyngeal wall had an abrasion most likely caused during TEE probe insertion. The ooze from the abraded pharynx could be stopped by coagulating the bleeder using bipolar diathermy. An approximate estimate of blood loss from the oropharynx was 750 mL (assessed using the gravimetric method). The oral cavity was suctioned continuously using a suction catheter placed in the oral cavity. The patient required 4 U of packed red cells and 6 U of fresh frozen plasma to counter the hemorrhage caused by surgery and the pharyngeal trauma. Although trauma during the insertion of a TEE probe has been reported, the circumstances under which the oropharyngeal trauma occurred in these cases were different. Because of these 2 cases, we now insert the TEE probe under direct vision whenever difficulty in endotracheal intubation is encountered. It is logical to expect the anatomic variation of the airway that causes difficulty in endotracheal intubation will also produce difficult conditions for the insertion of the TEE probe. If access to the oral cavity is not available with an unhindered view of the airway, the TEE probe should not be inserted. We agree with Piercy et al about reconsidering the use of TEE monitoring after careful consideration in each case. One must reconsider the decision to insert a TEE probe when encountering conditions causing difficult intubation or abnormal patient position at the time of probe insertion or compromised accessibility of the oral cavity.