Transesophageal Echocardiography Probe Insertion Research Articles

Factors predicting difficulty in insertion of real-time-three-dimensional transesophageal echocardiography probe in adult patients undergoing cardiac surgery.

Transesophageal echocardiography (TEE) probe insertion may be associated with many complications. Demographic factors and airway conditions such as high Mallampati scores (MMC) and Cormack-Lehane grades (MCLG) are likely to have an impact on its ease of insertion. The primary aim of this study was to identify the predictive factors for difficult real-time-three-dimensional TEE probe insertion. A total of 153 adult patients undergoing cardiac surgery were prospectively evaluated. The upper airway manipulations required for TEE probe placement were jaw thrust, reverse Sellick's maneuver, and laryngoscopy. All the patients who required airway manipulations were grouped under difficult TEE probe placement group. We evaluated the patients' predictive factors such as demographic characteristics and factors related to difficult intubation. Out of 153 patients, 123 were males and 30 were females. Overall, 27.5% (n = 42) patients had difficulty in probe placement. About 31.7% (n = 39) males had difficulty in TEE probe placement against 13% (n = 4) females (P-value 0.045). Difficulty in TEE probe placement was found in 72.7% (n = 16) of obese patients (body mass index [BMI] > 30), compared to 18.6% (n = 17) in the patients with BMI less than 25 (P-value < 0.001). Probe insertion was significantly more difficult in the presence of MMC III and IV (50%, n = 18) compared to class I (19.2%, n = 10) (P-value 0.001) and MCLG III (73.3%, n = 22) compared to grade I (11.1%, n = 7) (P-value 0.001). Male gender, obesity, higher grades of MMC and MCLG were found to be the risk factors for difficult TEE probe placement in anesthetized patients.

Use of a Video Laryngoscope to Reduce Complications of Transesophageal Echocardiography Probe Insertion: A Multicenter Randomized Study

The objective of this multicenter study was to test the hypothesis of whether the use of a video laryngoscope (VL) reduces complications related to transesophageal echocardiography (TEE) probe insertion. A multicenter randomized control study. At 5 tertiary care level hospitals. Three hundred sixty-three adult patients undergoing elective cardiac surgery. The patients were randomized into 2 groups-the conventional group (C group; n=177) and the VL group (n=186) for TEE probe insertion. The primary endpoint of the study was the incidence of oropharyngeal injury, which was defined as blood at the tip of the TEE probe at the end of surgery and/or evidence of injury on VL examination at the end of surgery. The secondary endpoints of the study were the number of attempts required for successful TEE probe insertion and the relation between the esophageal inlet and the larynx. There was a higher incidence of injuries in the C group (n=26; 14.7%) compared to the VL group (n=14; 7.5%; p=0.029). The number of attempts for probe insertion was significantly lower in the VL group (p=0.0023). The most common relation between the esophageal inlet and the larynx was posterolateral (n=88; 47%), followed by posterior (n=77; 41%) and lateral (n=21;12%). The use of VL was associated with a lesser incidence of injury compared to the conventional technique, and its use for this purpose is recommended. The use of VL for probe insertion resulted in fewer attempts compared with the conventional technique. Significant variations do exist in the relation between the esophageal inlet and the larynx, and direct visualization with VL may contribute to better safety.

The Effect of Intraoperative Transesophageal Echocardiography Probe Placement on the Endotracheal Tube Cuff Pressure in Adult Patients Undergoing On-Pump Cardiac Surgery

The study was directed toward documentation of the effect of transesophageal echocardiography (TEE) probe insertion on the endotracheal tube cuff pressure (CP) in adult patients undergoing on-pump coronary bypass surgery. The primary objective of this study was to assess whether CP reaches supranormal pressures during the different stages of intraoperative TEE examination. The secondary objective was to observe the effect of TEE probe placement on the ventilation parameters. A prospective observational study. At a tertiary care cardiac center. Thirty-four cardiac surgical patients older than 18 years of age who required intraoperative TEE examination. TEE probe insertion. Following the induction of general anesthesia and tracheal intubation, a TEE probe was introduced. The endotracheal tube CP was recorded at 5 time zones: Before TEE probe insertion, during the insertion of the probe, during probe manipulation, probe in the transgastric position, and during removal of the probe. A nonparametric test was used for comparing intracuff pressure between pairs of time zones. There was a statistically significant difference in CP values between the baseline and those during different time zones (chi-square test=134.77, degrees of freedom=4, p=0.001). There was a statistically significant difference in the peak pressure between different time points compared to baseline (p=0.0001). TEE probe placement in patients with tracheal intubation may be associated with a significant increase in CP well above the baseline pressure. With the possibility of the mean arterial pressures during cardiopulmonary bypass being substantially lower than expected, the findings of the current study raised the concern of predisposing the tracheal mucosa to hypoperfusion, with subsequent temporary or permanent tracheal damage. Hence, at least a baseline estimation of the endotracheal tube CP at the time of tracheal intubation, with the help of a pressure gauge in the operating room, may be considered as a safe practice.

The superiority of midazolam-pethidine combination in three different anesthetic methods applied in conscious sedation during transesophageal echocardiography procedure

Background: During the transesophageal echocardiography (TEE) procedure, as in many other diagnostic semi-invasive applications, moderate sedation is preferred over deep sedation. Rarely, patients who cannot tolerate moderate sedation may require deep sedation when difficulties are encountered during TEE probe insertion. Although many different methods have been tried for the TEE procedure in clinical practice, the most appropriate sedation method is still controversial. Aims and Objectives: We aimed to evaluate the clinical effects of three different sedoanalgesia methods consisting of midazolam, propofol, and midazolam-pethidine combination protocols applied for conscious sedation in the patients undergoing a TEE procedure, and to evaluate the patient and doctor satisfaction during the procedure. Materials and Methods: One-hundred twenty five patients who underwent TEE for diagnostic purposes in our hospital were included consecutively in our prospective randomized trial. The patients were divided into three groups as those who were administered midazolam (group M), propofol (group Pr), and midazolam-pethidine (group MPe) during the TEE procedure. Results: In the MPe group, both patient and doctor satisfaction were significantly higher than the two groups. The rate of difficulty in probe placement was lower in the Pr and MPe groups compared to the M group (P&lt;0.05). Conclusion: In this study, it has been observed that conscious sedation with the combination of midazolam-pethidine was significantly advantageous in terms of patient and physician satisfaction compared to the use of only midazolam and only propofol.

Airtraq® videolaryngoscope guidance for the difficult transesophageal echocardiography probe insertion in the sedated patient

Airtraq® videolaryngoscope guidance for the difficult transesophageal echocardiography probe insertion in the sedated patient

The Effect of Transesophageal Echocardiography Probe Insertion in Endotracheal Tube Cuff Pressure in Adult Cardiac Surgical Patients.

Background and Aims: Insertion of transesophageal echocardiography probe in cardiac surgical patient is a routine practice for surgical planning and decision making. However it may increase the endotracheal tube cuff pressure as it lies adjacent to the posterior wall of trachea. The aim of this study is to evaluate the changes in cuff pressure after insertion of the transesophageal echocardiography probe and after completion of initial manipulation of the transesophageal echocardiography probe during various examinations in adult cardiac surgical patients.&#x0D; Methods: Thirty six patients undergoing elective cardiac surgery requiring Transesophageal Echocardiography (TEE) monitoring were enrolled in the study. After induction of general anesthesia and endotracheal intubation cuff pressure were measured at 3 points of time; just after intubation (T1), after transesophageal probe insertion (T2) and after initial completion of TEE study (T3). The mean increase in cuff pressure at various point of time were compared.&#x0D; Results: The cuff pressure (mean±SD) at T1, T2 and T3 were 24.61±2.72, 30.22±5.61 and 32.25±4.45 cm of H2O respectively.The cuff pressure increased significantly from T1 to T2 (p&lt;0.001) and from T1 to T3 (p&lt;0.001). The cuff pressure was &gt; 30 cm of H2O in 18 (50%) of patients at T3 which was readjusted back to 25-30 cm of H2O by with drawing air from the cuff.&#x0D; Conclusion: Endotracheal tube cuff pressure should be routinely monitored either intermittently or continuously after transesophageal echocardiography probe insertion till it is in situ and pressure should be readjusted to avoid unwanted complications.

Novel Method of Administering Pharyngeal Anesthesia before Transesophageal Echocardiography

The most unpleasant reaction upon insertion of a transesophageal echocardiography (TEE) probe is a gag reflex, which is a normal defense mechanism that prevents foreign bodies from entering the trachea, pharynx, and larynx. The gag reflex causes excessive salivation, which may increase the risk of aspiration. When extreme, a hyperreflexive gag may result in lacrimation, sweating, fainting, or overt panic attacks, which further impair the ease of TEE probe insertion, may force a deeper level of conscious sedation with increased associated risk, and could impact future decisions by patients needing repeat TEE.

McGRATH MAC video laryngoscope assistance during transesophageal echocardiography may reduce the risk of complications: a manikin study

BackgroundAlthough transesophageal echocardiography (TEE) is considered a relatively safe diagnostic monitoring method, blind probe insertion is associated with pharyngeal trauma. Through visual observation of the esophageal inlet with the McGRATH video laryngoscope, it may be possible to insert the TEE probe at an appropriate angle and prevent pharyngeal trauma. We conducted a manikin study to investigate whether the use of the McGRATH video laryngoscope for TEE probe insertion reduced the pressure on the posterior pharyngeal wall.MethodsTwenty-seven junior (inexperienced group) and 10 senior (experienced group) anesthesiologists participated in this study. The TEE probe was inserted into an airway manikin in a blind fashion (blind group) or under visualization with the McGRATH (McGRATH group) video laryngoscope (three times each). A sealed bag filled with normal saline was placed on the back of the posterior pharyngeal wall of the manikin and connected to a patient monitoring system via a pressure transducer. We measured the internal bag pressure and approximated this value to the pressure on the posterior pharyngeal wall.ResultsThe pressure on the posterior pharyngeal wall was significantly lower in the McGRATH group than in the blind group (p < 0.001) and was significantly reduced when the McGRATH was employed in both the inexperienced (p < 0.001) and experienced (p < 0.001) groups.ConclusionsThese findings suggest that TEE probe insertion under the assistance of the McGRATH video laryngoscope can reduce the pressure on the posterior pharyngeal wall, regardless of the clinician’s experience, and may inform clinical practice with the potential to reduce probe insertion-associated complication rates.

Videolaryngoscopy for transesophageal echocardiography probe insertion: a systematic review and meta-analysis of randomized controlled trials.

Transesophageal echocardiography (TEE) is a well-established procedure, but serious complications may occur. This systematic review and meta-analysis assessed the utility of videolaryngoscopy-assisted technique in TEE probe insertion. We performed a systematic search in MEDLINE, EMBASE, CENTRAL, and ICTRP. We included RCTs comparing TEE probe insertion techniques assisted with videolaryngoscopy and with any other insertion technique in adult patients. Primary outcome measures were (1) the number of attempts before successful TEE probe insertion, and (2) the risk of any procedural injury to related structures. The secondary outcome measure was time to TEE probe insertion. In total, three studies (n = 266) were included in this systematic review. Overall, a significantly less number of attempts were required with videolaryngoscopy-assisted insertion (mean difference [MD] - 0.60; 95% confidence interval [CI] - 0.73, - 0.46; low quality of evidence). Videolaryngoscopy-assisted technique was also associated with smaller risk of complications (risk ratio [RR] 0.17; 95% CI 0.05, 0.62; low quality of evidence). There was no significant difference in time to probe insertion (MD - 8.57; 95% CI - 26.31, 9.16; very low quality of evidence). The use of videolaryngoscopy for TEE probe insertion is associated with a significant reduction in the number of attempts and complication rate.

Echonavigator in children with congenital heart diseases

Transesophageal echocardiography (TEE) has become indispensable in catlab to guide some percutaneous interventions as a complimentary imaging for fluoroscopy. However the tow imaging modalities are presented separately and differently. Echonavigator® is an innovative software enabling fusion between the tow imaging modalities on the same screen. We aimed to assess the feasibility of Echonavigator system to guide interventional procedure in children with CHD, and to present our initial clinical experience using this software. We enrolled all children underwent interventional catheterization needing guidance by TEE from December 2015 to December 2017. Patients weighting less than 20 kg or having a contraindication for TEE were excluded. TEE was realized by using X7-2t TEE probe connected to an echocardiographic system (EPIC). Fluoroscopy was realized using Allura Xper FD/10 system. Image fusion was attempted in all patients using Echnavigator system. Markers were positioned on the target zone on echocardiographic images and projected to the interventionists on the fusing screen. Fifty-one patients with CHD were included, mean age was 8 years old (5.5–14), mean weight was 25 kg (20–36 kg). 36 patients underwent Atrial septal defect closure, 10 ventricular septal defect closure, 3 aortic valve dilatation and 2 right ventricular outflow tract revaluation. Image fusions were successfully obtained in all patients in real time during all steps of procedure. No complication related to TEE probe insertion or manipulation was observed. Markers were successfully positioned in the all target zones and automatically projected to the interventionist on the fusion screen. Echonavigator system is feasible and safe to guide interventional catheterization in children with CHD. It enables better appreciation of anatomical relationships and improves confidence of interventionist to achieve the target zones.

Usefulness of echocardiographic-fluoroscopic fusion imaging in children with congenital heart diseases

Transesophageal echocardiography (TEE) has become indispensable in Cat-lab to guide some percutaneous interventions as a complimentary imaging for fluoroscopy. The tow imaging modalities are presented separately and differently making the interpretation of the anatomic spatial relationships not easy. Echonavigator® (Philips) software enables fusion between the two imaging modalities on the same screen. Few data on its feasibility and its clinical applications in children are currently available. Assess the feasibility of Echonavigator system to guide interventional procedure in children with CHD, and to present our initial clinical experience using this software in pediatric Cat-lab. We enrolled all children underwent interventional catheterization needing guidance by TEE from December 2015 to December 2017. Patients weighting less than 20 kg were excluded. TEE was realized using X7-2t TEE probe connected to an echocardiographic system (EPIC). Fluoroscopy was realized using Allura Xper FD/10 system. Image fusion was realized using Echnavigator system. Markers were positioned on the target zone on echocardiographic images and projected to the interventionists on the fusing screen. Fifty-one patients with CHD were included, mean age was 8 years old (5.5–14), mean weight was 25 kg (20–36 kg). Thirty-six patients underwent ASD closure, 10 VSD closure, 3 aortic valve dilatation and 2 RVOT revaluations. Image fusions were successfully obtained in all patients during all steps of procedure ( Fig. 1 ). No complication related to TEE probe insertion or manipulation was observed. Markers were successfully positioned in the all target zones and automatically projected to the interventionist on the fusion screen. Echonavigator system is feasible and safe to guide interventional catheterization in children with CHD. It enables better appreciation of anatomical relationships and improves confidence of interventionist to achieve the target zones.

Visually guided TEE probe insertion, making a case based on anatomic variation: A cadaveric study.

The variations in upper esophageal anatomy currently are unknown. This study was carried out to evaluate this variation and assess its impact on transesophageal echocardiography probe insertion. We included 9 consecutive cadavers studied at the University of Maryland School of Medicine's Clinical Surgical Laboratory. Each cadaver was first intubated blindly by an echocardiographer (KAA) and then under direct vision with a UE Medical VL 400 video laryngoscope (Newton, MA) by an anesthesiologist (JD). The visually guided method took a shorter average time (19.4±13.4seconds) and fewer passes (2.4±2.1 passes) than blind insertion (30.3±19.1seconds, 5.3±3.3 passes). None of the cadavers had the esophagus located directly posterior to the trachea. The esophageal hiatus was posterior and to the right of the trachea in most (n=6); in these, the traditional "forward" jaw thrust helped to open the esophageal hiatus. Two cadavers had the esophagus and trachea located almost side by side, and in these the "forward" jaw thrust method failed. Instead, the jaw needed to be pulled to the left in order to advance the probe. This is the first study to describe anatomic variations in the location of and relationship between the upper esophageal sphincter and the larynx for the purpose of transesophageal echocardiography probe insertion. Awareness of the side-by-side anatomic variation can help to improve esophageal intubation by prompting the use of a new "pull to the side" technique instead of the traditional "forward" jaw thrust.

Echonavigator® in children with congenital heart diseases

Transesophageal echocardiography (TEE) has become indispensable in cat-lab to guide some percutaneous interventions as a complimentary imaging for fluoroscopy. However, the tow imaging modalities are presented separately and differently making the interpretation of the anatomic spatial relationships not easy. Echonavigator ® (Philips Healthcare, Best, The Netherlands) is an innovative software enabling fusion between fluoroscopic and echocardiographic image on the same screen. Few data on its feasibility and its clinical applications in children with congenital heart diseases (CHD) are currently available. To assess the feasibility of Echonavigator ® system to guide interventional procedure in children with CHD, and to present our initial clinical experience using this software for guidance of percutaneous treatment of children with CHD. We enrolled all children underwent interventional catheterization needing guidance by TEE from December 2015 to December 2017. Patients weighting less than 20 kg or having a contraindication for TEE were excluded. TEE was realized by a pediatric cardiologist using X7-2t TEE probe connected to an echocardiographic system (EPIC). Fluoroscopy was realized by interventional cardiologist using Allura Xper FD/10 system (Philips Healthcare). Image fusion was attempted in all patients using Echnavigator ® system. Markers were positioned on the target zone on echocardiographic images and projected to the interventionists on the fusing screen. Fifty-one patients with CHD were included, mean age was 8 years old (5.5–14), mean weight was 25 kg (20–36 kg). 36 patients underwent atrial septal defect closure, 10 ventricular septal defect closure, 3 aortic valve dilatation and 2 right ventricular outflow tract revaluation. Image fusions were successfully obtained in all patients in real time during all steps of procedure ( Fig. 1 ). No complication related to TEE probe insertion or manipulation was observed. Markers were successfully positioned in the all target zones and automatically projected to the interventionist on the fusion screen. Echonavigator ® system is feasible and safe to guide interventional catheterization in children with CHD. It enables better appreciation of anatomical relationships and improves confidence of interventionist to achieve the target zones.

The Effect of Transesophageal Echocardiography Probe Placement on Intracuff Pressure of an Endotracheal Tube in Infants and Children

To evaluate the effects of transesophageal echocardiography (TEE) probe insertion on the endotracheal cuff pressure (CP). Prospective observational study. Single standing, not-for-profit pediatric hospital. A total of 80 pediatric patients (aged 6 days to 18.4 years) who underwent cardiac surgery and intraoperative TEE. None. Following anesthesia induction and endotracheal intubation, the CP was recorded at 4 points: before the insertion of the TEE (P1), at TEE insertion (P2), during TEE examination (P3), and after the probe was advanced into the stomach (P4). Twenty patients were enrolled in each of the following age groups:<1 year of age; 1-4 years of age; 5-8 years of age; and 9-18 years of age. CP was compared between pairs of time points using paired t-tests, and differences in CP over time were compared among age groups using repeated-measures analysis of variance. CP at P1, P2, P3, and P4 was 18.7±11.6, 26.7±14.4, 22.3±12.4, and 20.6±12.6 cmH2O, respectively. Although CP significantly increased from P1 to P2 (p<0.001), there was no significant difference between P1 and P4 (95% CI; -0.3 to 4.1; p = 0.083). There was no significant difference in CP change based on the age of the patient. Following a transient increase in CP with TEE probe insertion, the CP returned to baseline after the tip of the TEE probe was advanced into the stomach. There was no variation among age groups in the magnitude of the CP change during the study.

Monitoring of left ventricular assist device implantation and set-up with miniaturized transoesophageal echocardiography: Initial experience at La Pitié-Salpêtrière Hospital and possible application fields.

Left ventricular assist devices are valuable options for mechanical circulatory support in patients with severe heart failure as a bridge to cardiac transplantation, to recovery, or as destination therapy. Transoesophageal echocardiography plays a key role in the management of left ventricular assist device patients; either in guiding the device implantation or in post-operative haemodynamic assessment. The aim of this observational study is to investigate the usefulness of a miniaturized transoesophageal echocardiography probe designed for continuous haemodynamic monitoring (haemodynamic transoesophageal echocardiography; ImaCor, Garden City, NY) in the haemodynamic assessment of patients undergoing left ventricular assist device implantation. Between June 2014 and September 2014, seven consecutive patients underwent left ventricular assist device implantation for severe heart failure. A haemodynamic transoesophageal echocardiography probe was used for continuous haemodynamic monitoring in the pre-, intra- and post-operative periods. All procedures were performed by haemodynamic transoesophageal echocardiography-trained physicians. All data were recorded and used without need of a further haemodynamic device. The average number of haemodynamic assessments in each patient was 5.3. The average number of haemodynamic assessments leading to therapeutic changes in each patient was 2.6. The mean duration of haemodynamic transoesophageal echocardiography probe insertion was approximately 20 hours (9 hours - 72 hours). No device complications were noticed during this period. This observation suggests that haemodynamic monitoring using the haemodynamic transoesophageal echocardiography system in left ventricular assist device patients is feasible after a brief training period. The overall impact of haemodynamic transoesophageal echocardiography use in these patients is yet to be determined and further studies are still required.

Safety of transesophageal echocardiography during extracorporeal life support.

Use of extracorporeal life support (ECLS) has significantly increased in critically ill patients refractory to medical management. ECLS requires systemic anticoagulation to avoid thromboembolic complications and superimposed coagulopathies are common. Transesophageal echocardiography (TEE) is frequently employed to assess cannula position and cardiac function during extracorporeal therapy. The goal of this study was to assess whether TEE probe insertion and removal in systemically anticoagulated ECLS patients was safe compared to patients without ECLS and normal coagulation studies. Eighty-seven separate TEE examinations in 53 adult ECLS patients were analyzed. Detailed complication profiles were logged for each patient from initiation through discontinuation of ECLS. Routine coagulation testing was recorded within two hours prior to the TEE exams. Controls consisted of age- and gender-matched patients undergoing perioperative TEE without ECLS and normal coagulation (N=87). Overall TEE-associated morbidity in ECLS patients was 2.3% and consisted of minor oropharyngeal bleeding (2/87 TEE exams) exclusively. The patients presenting with oropharyngeal bleeding received heparin for anticoagulation and had two or more abnormal coagulation studies at the time of TEE. Seventy-nine percent of ECLS patients received intravenous heparin infusions, 6.8% argatroban and 3.4% epoprostenol. Ten-point-eight percent of patients were not anticoagulated at the time of TEE because of pre-existing bleeding complications and/or deranged plasmatic coagulation profiles. No major complications (e.g., esophageal perforation, gastrointestinal bleeding, accidental extubation) were recorded in either group. TEE remained safe in critically ill patients under ECLS, despite systemic anticoagulation, during probe insertion, manipulation and removal. TEE-related complications pertained solely to oropharyngeal bleeding amenable to conservative management.

Use of McGrath MAC Videolaryngoscope to Assist Transesophageal Echocardiography Probe Insertion in Intubated Patients.

Transesophageal echocardiography (TEE) probe insertion with the conventional blind insertion technique may be difficult in anesthetized and intubated patients. The use of a videolaryngoscope may facilitate the insertion of the TEE probe. The aim of this study was to compare the conventional technique with the use of the McGrath MAC videolaryngoscope for TEE probe insertion in terms of success rate, duration of insertion, and complications in patients undergoing cardiovascular surgery. A prospective, randomized study. Training and research hospital. Eighty-six adult patients undergoing cardiovascular surgery were included. Eighty-six adult patients were randomized into 2 groups: conventional group (n = 43) and McGrath videolaryngoscope group (n = 43). Success rates, duration of insertion, complications, and hemodynamic changes during insertion were recorded. The success rate of TEE probe insertion at the first attempt was higher in the McGrath videolaryngoscope group (90.5%) than in the conventional group (43.9%) (p = 0.012). The mean duration for successful insertion of the TEE probe at the first attempt was longer in the McGrath videolaryngoscope group (24 s v 11 s) (p = 0.016). The total time for successful insertion of the TEE probe was similar in both groups. Pharyngeal injuries were observed more frequently in the conventional group (17.1% v 2.4%) (p = 0.037). The rate of blood presence on the probe tip in the conventional group was higher than in the McGrath group (21.9% v 4.8%). There were no statistical differences between the 2 groups in systolic blood pressure, mean arterial pressure, diastolic blood pressure, and heart rate before and after TEE insertion. The use of the McGrath MAC videolaryngoscope for TEE insertion in cardiovascular surgery patients increases the success rate and reduces pharyngeal injuries compared to the conventional technique. The use of the McGrath MAC videolaryngoscope for TEE insertion causes similar hemodynamic changes as in the conventional blind insertion technique.

McGRATH MAC video laryngoscope for insertion of a transoesophageal echocardiography probe: A randomised controlled trial.

BACKGROUNDTransoesophageal echocardiography (TOE) probe insertion in anaesthetised patients can cause pharyngeal and oesophageal injuries. Kim et al. have shown that insertion assisted by a Macintosh laryngoscope can reduce such complications but it may sometimes be difficult to observe the passage of a TOE probe. The McGRATH MAC (McGRATH) has been shown to provide a better view of the glottis, piriform fossa and oesophageal inlet during tracheal intubation than the Macintosh.OBJECTIVEWe hypothesised that the McGRATH provided better visualisation of the oesophageal inlet and was useful as an aid to TOE probe placement, possibly reducing the incidence of pharyngeal injury related to insertion, compared with the Macintosh.DESIGNA randomised controlled trial.SETTINGThe study was conducted in a university hospital from February to December 2014.PATIENTSOne hundred patients undergoing elective surgery under intraoperative TOE monitoring were randomised to either a Macintosh group or a McGRATH group.INTERVENTIONSMacintosh and McGRATH were used to visualise the passage of the TOE probe and guide its insertion.MAIN OUTCOME MEASURESVisibility of the oesophageal inlet, the number of TOE insertion attempts and incidence of pharyngeal mucosal injury after the TOE probe had been removed were assessed.RESULTSThe percentage of patients in whom the oesophageal inlet was visible was higher in the McGRATH group (88%) than in the Macintosh group (41%) (P < 0.01). The number of TOE probe insertion attempts was significantly smaller in the McGRATH group than in the Macintosh group (P = 0.039). The incidence of pharyngeal mucosal injury was significantly smaller in the McGRATH group (4%) than in the Macintosh group (16%; P = 0.042).CONCLUSIONThe McGRATH provided a better view of the oesophageal inlet and was useful as an aid to TOE probe placement, possibly reducing the incidence of pharyngeal injury related to its insertion.TRIAL REGISTRATIONUniversity Hospital Medical Information Network in Japan (UMIN) 000012970.

Temporomandibular joint dislocation following trans-oesophageal echocardiography probe insertion

Temporomandibular joint dislocation following trans-oesophageal echocardiography probe insertion

Effect of Jaw Thrust on Transesophageal Echocardiography Probe Insertion and Concomitant Oropharyngeal Injury

The aim of this study was to evaluate the effect of jaw thrust on transesophageal echocardiography probe insertion and concomitant oropharyngeal injury. A prospective, randomized study Medical center governed by a university hospital Forty-two adult patients undergoing cardiovascular surgery were included. After the induction of anesthesia, a transesophageal echocardiography probe was inserted using an anterior jaw lift technique (conventional group, n = 21) or a jaw thrust-assisted technique (jaw thrust group, n = 21). The incidence of oropharyngeal injury, number of insertion attempts, blood on the probe tip, and presence of persistent oropharyngeal bleeding were evaluated. In the conventional group, oropharyngeal injury occurred more frequently than in the jaw-thrust group (52.4% v 9.5%, respectively; p = 0.006). Regarding transesophageal echocardiography probe insertion, the conventional group required more attempts than the jaw-thrust group (p = 0.043). The incidence of blood on the probe tip was higher in the conventional group than in the jaw-thrust group (p = 0.020), but the presence of persistent oropharyngeal bleeding was similar between the 2 groups. The jaw-thrust maneuver facilitated the insertion of the transesophageal echocardiography probe and reduced concomitant oropharyngeal injury.