Interference with Innominate Artery Perfusion Due to a Transesophageal Echocardiography Probe in a Child

Abstract

MECHANICAL PROBLEMS associated with intraoperative transesophageal echocardiography (TEE) are well known. A hazard of intraoperative TEE during pediatric cardiac surgery has been described earlier in this journal.1Maddali M.M. Alnaabi M.J. Kandachar P.S. et al.A hazard of transesophageal echocardiography in a neonate.J Cardiothorac Vasc Anesth. 2017; 31: e24Abstract Full Text Full Text PDF Scopus (1) Google Scholar We report an additional instance of selective vascular occlusion in a pediatric cardiac surgical patient that was related to the manipulation of a TEE probe. A 5-month-old female (weight 4.6 kg, height 61.5 cm) with Down syndrome was admitted to authors’ institute for elective surgical repair of an atrioventricular septal defect and ligation of a patent ductus arteriosus. After induction of general anesthesia under routine American Society of Anesthesiologists–recommended monitoring modalities, the right radial artery, right dorsalis pedis artery, and right internal jugular vein were cannulated under aseptic precautions. The lower limb artery was cannulated because there was suspicion of a coarctation of aorta. Cerebral oximetry was monitored using near-infrared spectroscopy probes (Covidien, Mansfield, MA). As an adjunct to routine perioperative monitoring, a micro transesophageal probe (Philips S8-3t pediatric transesophageal transducer; Philips Healthcare, Andover, MA) was inserted through the oropharynx atraumatically. At that point, the anesthesiologists observed that the right radial artery waveform was dampened with a simultaneous drop in right sided cerebral oximetry readings (Fig 1). The heart rate, right dorsalis pedis artery waveform, arterial oximetry readings from the lower limb, and left cerebral oximetry readings were unaffected. We presume that the micro TEE probe obstructed blood flow in the right innominate artery, which was recognized immediately because of the changes produced in the right radial artery pressure waveform and the right cerebral oximetry readings. The incidence of neurologic dysfunction after pediatric open heart surgeries was reported to be as high as 25%.2Ferry P.C. Neurologic sequelae of open-heart surgery in children. An ‘irritating question’.Am J Dis Child. 1990; 144: 369-373Crossref PubMed Scopus (234) Google Scholar The high incidence of neurologic complications after pediatric open heart surgeries mandates that adequate attention be paid toward any manipulation that can interfere with cerebral blood flow. Innominate artery perfusion can be monitored invasively by right arm invasive arterial pressure monitoring or noninvasively by pulse oximetry readings of the right upper limb or by right cerebral oximetry. These monitoring modalities could, to some extent, be used to assess the adequacy of perfusion in the innominate artery territory. There might be instances when none of these modalities might be available. Under such circumstances, if a mechanical problem owing to a TEE probe insertion occurs, such as that described here, and is left undetected, it might result in a subsequent poor neurologic outcome. Toward this end, our report could serve as a caution to practicing anesthesiologists to be aware of an additional mechanical problem that is associated with intraoperative TEE, which if left undetected could result in an unexplained neurologic complication.