Anesth Analg 2002;95:561-563
© 2002 International Anesthesia Research Society
CARDIOVASCULAR ANESTHESIA
Insertion of the Transesophageal Echocardiography Probe via Endoscopy Mask
Toshiya Shiga*,
Tetsuo Inoue*,
Zen’ichiro Wajima*, and
Ryo Ogawa
*Department of Anesthesia, Chiba Hokusoh Hospital, Nippon Medical School, Chiba; and Department of Anesthesiology, Nippon Medical School Hospital, Tokyo, Japan
Address correspondence and reprint requests to Toshiya Shiga, MD, PhD, Department of Anesthesia, Chiba Hokusoh Hospital, Nippon Medical School, Kamagari 1715, Inba-mura, Inba-gun, Chiba 270-1694, Japan. Address e-mail to shiga/anesth{at}nms.ac.jp
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Abstract
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IMPLICATIONS: Transesophageal echocardiography (TEE) has not been used during airway manipulation to assess the occasional occurrence of hemodynamic instability that occurs especially in cardiac patients. We describe a new technique using an endoscopy mask to perform TEE monitoring during airway manipulation with a large concentration of supplemented oxygen.
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Introduction
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Although transesophageal echocardiography (TEE) is useful in a variety of clinical settings, its use is still incompatible with the induction of anesthesia for laryngoscopy or tracheal intubation. Anesthesiologists often encounter patients with coronary artery disease in whom the most common adverse cardiovascular event related to intubation is probably myocardial ischemia (1). In these patients, myocardial oxygen extraction increases during laryngoscopy and intubation after the induction of inhaled or IV anesthesia (2). Nevertheless, monitoring for myocardial ischemia by echocardiography during this period is yet to be widely used.
The Patil-Syracuse mask (Senko Medical Instrument Manufacturing Company, Ltd, Tokyo, Japan) was originally developed to allow fiberoptic laryngoscopy through a flexible port on the mask without interruption of oxygen delivery in patients who are difficult to intubate (3,4). A second generation of this prototype is a clear plastic shell endoscopy mask with a flexible silicon membrane port (Endoscopy Mask; VBM Medizintechnik GmbH, Sulz am Neckar, Germany) (5). We have developed a new technique for facilitating TEE examination during anesthesia induction via either one of these two masks in patients with coronary artery disease or hypertension.
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Case Report
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We performed our new technique in three patients considered susceptible to myocardial ischemia: one undergoing orthopedic surgery, one undergoing a colectomy, and one undergoing an otolaryngosurgery. Two of these patients had a history of angina pectoris, and one had hypertension associated with left ventricular (LV) hypertrophy. The Patil-Syracuse mask was used in the first patient (Fig. 1), and the Endoscopy Mask was used in the other two (Fig. 2). Anesthesia was induced with midazolam 6–8 mg, fentanyl 50–100 µg, and vecuronium 6–10 mg. After initial mask ventilation with 100% oxygen, oxygen delivery was temporarily suspended for 5-10 s so the TEE probe could be passed into the esophagus. In one patient, blood pressure and heart rate slightly increased when the TEE probe was inserted, but the changes were slight (within +5%–10%). The mask ventilation was restarted, and adequate ventilation was confirmed by capnography. SpO2 remained at 98%–100% throughout the induction in all three cases. The details of the orthopedic surgical patient are described.
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Figure 1. Mask ventilation with the Patil-Syracuse mask (PS mask) in the presence of transesophageal echocardiography (TEE) probe. The open port located in the anterior part of the size no. 4.0 mask is 18 mm high by 10 mm in outer diameter. Outer diameter of biplane TEE probe is 11.5 mm.
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Figure 2. Mask ventilation with the Endoscopy Mask in the presence of transesophageal echocardiography (TEE) probe. The silicone membrane is located in the center of the mask with a 5.0-mm-diameter opening.
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A 73-yr-old woman with New York Heart Association class II was scheduled for repair of a left humeral fracture. Her medical history included angina pectoris treated with isosorbide dinitrate, hypertension managed with benidipine hydrochloride 8 mg/d, and electrocardiographic (ECG) abnormalities indicative of LV hypertrophy. Preoperative transthoracic echocardiographic examination revealed 14–15 mm LV wall thickness, calcification of the mitral and aortic valves, moderate mitral stenosis (estimated at 1.31 cm2), and mild aortic regurgitation, but no wall motion asynergy. The ejection fraction was 0.46, and the ratio of LV early diastolic filling to atrial filling was inverted (E/A ratio, 0.57), suggesting moderate systolic and diastolic dysfunction. Preoperative coronary angiography was not performed. Informed consent was obtained for the use of TEE and the Patil-Syracuse mask.
Benidipine hydrochloride 4 mg was administered on the morning of surgery. Roxatidine acetate hydrochloride, an H2-receptor antagonist, was given IV 20 min before surgery. A V-lead ECG monitor was applied, infusion of nitroglycerin (0.3 µg · mg-1 · min-1) was initiated, and continuous radial artery blood pressure monitoring was started. Anesthesia was induced with the aforementioned drugs. Ventilation was performed with 100% oxygen (6 L/min) delivery via a Patil-Syracuse mask with its port closed. A biplane probe (UST-5258S-5, Aloka Co, Ltd, Tokyo, Japan) was lubricated with 2% lidocaine jelly and connected to a TEE instrument (SSD-2000, Aloka). After insertion of the TEE probe, mask ventilation was restarted (Fig. 1). Routine TEE examination by a second anesthesiologist showed moderate left atrial dilation (left atrial distance >4 cm); other findings were similar to those of the previous examination. We focused on the short- and long-axis views of the LV because the former displays the myocardial area that includes all three main coronary arteries and the latter reveals the ventricular apex (6). No new segmental wall motion abnormalities appeared; the patient’s blood pressure was 105/85 mm Hg and her heart rate (HR) was 75 bpm. With the TEE probe at the left side of her mouth, the trachea was intubated with a silicon endotracheal tube. After intubation, several supraventricular premature contractions occurred, but the patient’s systolic blood pressure did not exceed 135 mm Hg, her HR remained less than 85 bpm, and no new segmental wall motion abnormalities were observed. Sevoflurane at 1–1.5 minimum alveolar anesthetic concentration in air was inhaled during surgery. After 1 h of surgery, the neuromuscular blockade was reversed with 0.5 mg of atropine and 1.5 mg of neostigmine, and the trachea was extubated.
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Discussion
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Numerous researchers have studied the use of TEE for monitoring intraoperative myocardial ischemia; however, TEE monitoring for ischemia during the anesthesia induction period has previously not been technically feasible. We have successfully performed TEE monitoring with the Patil-Syracuse mask and the Endoscopy Mask during airway manipulation for laryngoscopy or tracheal intubation.
The technique we described is useful both for cardiac surgery in which TEE examination is required throughout the procedure and noncardiac surgery requiring TEE from start to finish. This technique will have additional value in two other potential applications: when a nonsurgical patient (critically ill) undergoing TEE examination is not intubated and yet requires a large concentration of supplemental oxygen and when a nonsurgical patient undergoing TEE examination requires heavy sedation, necessitating high-flow oxygen supplementation and possibly a brief period of ventilatory support. The original intention of the Patil-Syracuse mask was to provide for large-concentration oxygen during fiberoptic endoscopy. We applied this function to provide 100% oxygen during TEE examination.
There may be some disadvantages to our technique. First, in patients for whom airway manipulation is expected to be difficult (e.g., those with a small or limited mouth opening or short neck), oral endotracheal intubation might be overly complicated because of the presence of the TEE probe. Therefore, our technique should be performed by a skilled, experienced anesthesiologist, particularly in a hemodynamically unstable patient. However, the anesthesiologist can convert promptly from TEE monitoring to fiberoptic intubation while using either of these endoscopy masks in the case of a difficult airway. Second, the risk of gastric insufflation and regurgitation of the gastric contents may be of concern. Although the esophagus was occupied by the TEE probe, the esophageal sphincter was breached. We used an H2-receptor antagonist in our patients, and no aspiration occurred, but it is unclear how much the risk of aspiration will increase by use of this technique.
Although extensive prospective studies under various conditions are required, we believe that our new technique provides for manipulation of the TEE probe during mask ventilation with large-concentration oxygen supplementation.
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References
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- Bishop MJ, Bedford RF, Kil HK. Physiologic and pathophysiologic response to intubation. In: Benumof JL, ed. Airway management: principles and practice. St Louis, MO: Mosby-Year Book, Inc, 1995: 102–3.
- Moffitt EA, Sethna DH, Bussell JA, et al. Effects of intubation on coronary blood flow and myocardial oxygenation. Can Anaesth Soc J 1985; 32: 105–11.[Medline]
- Patil V, Stehling LC, Zauder HL, Koch JP. Mechanical aids for fiberoptic endoscopy. Anesthesiology 1982; 57: 69–70.[Web of Science][Medline]
- Aoyama K, Yasunaga E, Takenaka I, et al. Positive pressure ventilation during fibreoptic intubation: comparison of the laryngeal mask airway, intubating laryngeal mask and endoscopy mask techniques. Br J Anaesth 2002; 88: 246–54.[Abstract/Free Full Text]
- Frei FJ, àWengen DF, Rutishauser M, Ummenhofer W. The airway endoscopy mask: useful device for fibreoptic evaluation and intubation of the paediatric airway. Paediatr Anaesth 1995; 5: 319–24.[Web of Science][Medline]
- Kahn RA, Konstadt SN, Louie EK, et al. Intraoperative echocardiography. In: Kaplan JA, Reich DL, Konstadt SN, eds. Cardiac anesthesia. 4th ed. Philadelphia, PA: WB Saunders, 1999: 435–9.
Accepted for publication May 10, 2002.
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F. Urdaneta
TEE Probe via Endoscopy Mask: The Right Thing at the Wrong Time?
Anesth. Analg.,
May 1, 2003;
96(5):
1527 - 1528.
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Abstract
Introduction
