Incidence of Sore Throat and Patient Complaints Transesophageal Echocardiography During
After Intraoperative Cardiac Surgery
Anders bwall, MD, Lisbeth StBhl, RN, and Gijran Settergren, MD To evaluate the incidence of postoperative side effects and patient complaints following transesophageal echocardiography (TEE), 57 patients were interviewed by questionnaire and examined by pharyngeal inspection, preoperatively. The patients were randomized to undergo surgery with or without intraoperative TEE, and a second interview and examination were performed in 48 patients on the second postoperative day using a double-blind protocol. Twenty-four of the patients were investigated by TEE over a period of 5.4 ? 2.3 hours and 24 had surgery without TEE. The intubation time for the two groups did not differ. There was no difference between controls and TEE patients with regard to painful swallowing evaluated by a visual analog scale. Furthermore,
I
NTRAOPERATIVE transesophageal echocardiography (TEE) has enjoyed increasing popularity and is now used routinely during cardiac surgery in many institutions because this semiinvasive technique can assess cardiac function intraoperatively.’ The TEE probe generates pressure against the esophageal wall, and thus there is a potential risk for esophageal damage.’ Bleeding from a distal esophageal tear has been described.’ Despite the fact that TEE involves blind manipulation of the ultrasound probe in the distal esophagus, intraoperative TEE is considered safe and no major complications of the procedure have been reported in a number of series.4-7 The present study was designed to evaluate the incidence of postoperative side effects and patient complaints related to the use of TEE during cardiac surgery, as assessed by interviewing and examining the patients, postoperatively.
MATERIALS
AND METHODS
Fifty-seven patients (42 men, 15 women; mean age 63.7 years, range 45-80) with no known esophageal disease scheduled for elective coronary artery revascularization or valvular surgery were included in the study. The study was approved by the Local Committee on Ethics, and the patients were included after obtaining their written informed consent. The patients underwent a standardized questionnaire interview and inspection of the pharynx on the day before surgery and were randomized to undergo surgery with or without intraoperative TEE. After premeditation with morphine and scopolamine, anesthesia was induced with midazolam (approximately0.1 mg/kg) and fentanyl (approximately 10 ug/kg/min). Neuromuscular blockade was achieved with pancuronium (0.1 mgikg). Anesthesia was maintained with a continuous infusion of fentanyl and midazolam (approximately 0.3 mg/h and 3 mgih, respectively). Droperidol (0.1 mgikg) was given before skin incision. Patients were intubated orotracheally and ventilated to achieve normocapnia. Moderate hypothermia, 28°C to 30°C was used during extracorporeal circulation. In patients randomly chosen for perioperative TEE, the attending anesthesiologist inserted a TEE ultrasound probe (Vingmed, Sound AS, Horten, Norway) into the esophagus with the aid of the laryngoscope, after the induction of anesthesia. The probe was 10 mm in diameter; the transducer at the tip of the probe was 15 mm in diameter. A bite guard was mounted over the probe; no latex sheath was used. Cardiac long-axis and short-axis images were visualized intermittently during surgery. The TEE probe was removed before transferring the patient to the intensive care unit. A gastric tube was
there was no difference between the controls and TEE patients regarding nausea or time elapsed from extubation to the first oral intake. No differences between the groups were found regarding the findings on pharyngeal inspection and no major complication attributable to the use of TEE occurred. A sore throat with painful swallowing was not a great problem for the patients in the present study; this indicates that endotracheal intubation rather than TEE caused the minor complaints. It is concluded that intraoperative TEE can be used without harmful postoperative pharyngeal side effects. Copyright o 1992 by W.B. Saunders Company
inserted orally in all patients at the induction of anesthesia and was removed before extubation. The patients were interviewed and examined again on the morning of the second postoperative day, both the interviewer and patient were unaware of whether TEE had been used. Painful swallowing was estimated using a lo-degree visual analog scale on which 1 denoted no pain and 10 denoted maximal pain.* The results obtained from the visual analog scale were analyzed statistically by means of the nonparametric Mann Whitney U test. Fisher’s exact test was applied to categorical data. Students t test was used to test the difference between the means of the two groups. RESULTS
Of the 57 patients included in the study, 9 could not be examined on the second postoperative day for various reasons. Two patients randomized for TEE were excluded because the probe was difficult to insert into the esophagus on the first attempt; further attempts were abandoned. Seven patients could not be examined because of prolonged ventilator treatment or perioperative death. The second interview and examination were performed on the second postoperative day in 48 patients, 24 of whom had been investigated by TEE during a period of 5.4 2 2.3 hours, and 24 patients who had undergone surgery without TEE. The results for these patients are presented in the Table. Seven patients in the TEE group and two patients in the control group were smokers. There was no difference in total endotracheal intubation time between the TEE and control groups. The score for painful swallowing determined from the visual analog scale did not differ between the groups (TEE, mean 1.8; controls, mean 1.6). There was no difference between groups in time elapsed from extubation to the first oral intake. Two patients in both the TEE and the
From the Department of Cardiothoracic Anaesthetics and Intensive Care, Karolinska Hospital, Stockholm, Sweden. Supported by grants from the Karolinska Hospital, Stockholm, Sweden. Address reprint requests to Anders 6wal1, MD, Department of Cardiothoracic Anaesthetics and Intensive Care, Karolinska Hospital, S-104 01 Stockholm, Sweden. Copyright o I992 by W.B. Saunders Company 1053-0770/92/0601-0004$03.00l0
Journalof Cardiothoracicand VascularAnesthesia, Vol6, No 1 (February), 1992:pp 15-16
15
16
OWALL, STAHL, AND SETTERGREN
Table 1. Complaints on the Second Postoperative Day TEE Group
Age (vrsl
Control
Group
Significance
65.6 t 7.8
60.8 + 9.0
NS
7
2
NS
14.4 + 7.3
12.7 2 6.2
NS
1.8+ 0.9
2.2 2 0.9
NS
Pain during swal-
Mean 1.8,
Mean 1.6.
NS
lowing (score)
range 1-4
range 1-4
Severe postopera-
2
2
NS
Reddened pharynx
2
3
NS
(no.1 Minor injury to lips
3
5
NS
Smokers (no.) Endotracheal
intu-
bation time (hrs) Time from extubation to first oral intake (hrs)
tive nausea (no.)
(no.) Abbreviation:
NS, nonsignificant
control group complained of severe postoperative nausea. Inspection of the oral cavity revealed a reddened pharynx in 2 TEE patients and 3 control patients. Minor injury to the lip was found in 3 TEE patients and 5 control patients. No major complication attributable to the use of TEE occurred. DISCUSSION
The findings of the present study imply that intraoperative TEE can be used during cardiac surgery without harmful pharyngeal side effects in the postoperative period. Minor complaints of sore throat by the patient are common after cardiac surgery using endotracheal intubation and delayed extubation. A sore throat with painful swallowing was not a great problem for the patients in the present
study. The minor complaints that occurred may have been attributable to the endotracheal intubation rather than TEE because no differences were found between the groups. The fact that the evaluation of patient complaints was postponed to the second postoperative day may have influenced the results. An interview at an earlier point in time might have shown more complaints and different findings at the pharyngeal inspection. On the other hand. the patients might have been difficult to examine because of sedation and analgesia. Further, because of the limited number of patients in this study, infrequent pharyngeal complications associated with TEE may remain undetccted. It was difficult to pass the probe into the esophagus in 7 patients in this study. The attending anesthesiologist in one of these cases was inexperienced with TEE, and only one attempt to insert the probe was made. These factors probably contributed to the relatively low success rate.” The interview and examination could not be performed on the second postoperative day in another 7 patients, which may have influenced the results. In the remaining 48 patients. this double-blind study showed no differences between patients who had undergone cardiac surgery with intraoperative TEE and those who had undergone surgery without TEE, regarding patient complaints, painful swallowing, and findings during the oral examination. A recent questionnaire study has demonstrated that TEE also is well tolcrated when performed in the awake unsedated patient.“’ Intraoperative TEE is performed during a period of several hours in patients who do not respond to manipulations ot the probe and who have been anticoagulated and hypothermic during the extracorporeal circulation. Despite these factors, it may be concluded from this study that TEE is well tolerated by the patient during cardiac surgery.
REFERENCES I. Seward HB, Khandheria BK, Oh JK, et al: Transesophageal echocardiography: Technique, anatomic correlations, implementation, and clinical applications. Mayo Clinic Proc 63:649-680,198s 2. Urbanowicz JH, Kernoff RS, Oppenheim G, et al: Transesophageal echocardiography and its potential for esophageal damage. Anesthesiology 72:40-43, 1990 3. Dewhirst WE, Stragand JJ, Fleming BM: Mallory-Weiss tear complicating intraoperative transesophageal echocardiography in a patient undergoing aortic valve replacement. Anesthesiology 731777-778, 1990 4. Cahalan MK, Litt L, Botvinick EH, Schiller NB: Advances in noninvasive cardiovascular imaging: Implications for the anesthesiologist. Anesthesiology 66:356-372, 1987 5. Abel MD, Nishimura RA, Callahan MJ, et al: Evaluation of intraoperative transesophageal two-dimensional echocardiography. Anesthesiology 66:64-68, 1987
6. Geibel A, Kasper ageal echocardiography Am J Cardiol62:337-339.
W, Behroz A, e:t al: Risk of trdnsoesophin awake patients with cardiac diseases. 1988
7. Pearson AC. Castello R, Labovitz AJ: Safety and utility of transesophageal echocardiography in the critically ill patient. Am Heart J 119:1083-1089. 1990 8. Huskisson EC: Visual analogue scales, in Melzack R (ed): Pain Measurement and Assessment. New York, NY, Raven Press, 1983, pp 33-37 9. Daniel WC, Erbel R, Kasper W. et al: Safety of transesophageal echocardiography, a multicenter survey of 10,419 examinations. Circulation 83:817-821. 1991 IO. de Belder MA, Leech MA. Camm AJ: Transesophageal echocardiography in unsedated outpatients: Technique and patient tolerance. J Am Sot Echo 2:375-379, 1989
After Intraoperative Cardiac Surgery
Anders bwall, MD, Lisbeth StBhl, RN, and Gijran Settergren, MD To evaluate the incidence of postoperative side effects and patient complaints following transesophageal echocardiography (TEE), 57 patients were interviewed by questionnaire and examined by pharyngeal inspection, preoperatively. The patients were randomized to undergo surgery with or without intraoperative TEE, and a second interview and examination were performed in 48 patients on the second postoperative day using a double-blind protocol. Twenty-four of the patients were investigated by TEE over a period of 5.4 ? 2.3 hours and 24 had surgery without TEE. The intubation time for the two groups did not differ. There was no difference between controls and TEE patients with regard to painful swallowing evaluated by a visual analog scale. Furthermore,
I
NTRAOPERATIVE transesophageal echocardiography (TEE) has enjoyed increasing popularity and is now used routinely during cardiac surgery in many institutions because this semiinvasive technique can assess cardiac function intraoperatively.’ The TEE probe generates pressure against the esophageal wall, and thus there is a potential risk for esophageal damage.’ Bleeding from a distal esophageal tear has been described.’ Despite the fact that TEE involves blind manipulation of the ultrasound probe in the distal esophagus, intraoperative TEE is considered safe and no major complications of the procedure have been reported in a number of series.4-7 The present study was designed to evaluate the incidence of postoperative side effects and patient complaints related to the use of TEE during cardiac surgery, as assessed by interviewing and examining the patients, postoperatively.
MATERIALS
AND METHODS
Fifty-seven patients (42 men, 15 women; mean age 63.7 years, range 45-80) with no known esophageal disease scheduled for elective coronary artery revascularization or valvular surgery were included in the study. The study was approved by the Local Committee on Ethics, and the patients were included after obtaining their written informed consent. The patients underwent a standardized questionnaire interview and inspection of the pharynx on the day before surgery and were randomized to undergo surgery with or without intraoperative TEE. After premeditation with morphine and scopolamine, anesthesia was induced with midazolam (approximately0.1 mg/kg) and fentanyl (approximately 10 ug/kg/min). Neuromuscular blockade was achieved with pancuronium (0.1 mgikg). Anesthesia was maintained with a continuous infusion of fentanyl and midazolam (approximately 0.3 mg/h and 3 mgih, respectively). Droperidol (0.1 mgikg) was given before skin incision. Patients were intubated orotracheally and ventilated to achieve normocapnia. Moderate hypothermia, 28°C to 30°C was used during extracorporeal circulation. In patients randomly chosen for perioperative TEE, the attending anesthesiologist inserted a TEE ultrasound probe (Vingmed, Sound AS, Horten, Norway) into the esophagus with the aid of the laryngoscope, after the induction of anesthesia. The probe was 10 mm in diameter; the transducer at the tip of the probe was 15 mm in diameter. A bite guard was mounted over the probe; no latex sheath was used. Cardiac long-axis and short-axis images were visualized intermittently during surgery. The TEE probe was removed before transferring the patient to the intensive care unit. A gastric tube was
there was no difference between the controls and TEE patients regarding nausea or time elapsed from extubation to the first oral intake. No differences between the groups were found regarding the findings on pharyngeal inspection and no major complication attributable to the use of TEE occurred. A sore throat with painful swallowing was not a great problem for the patients in the present study; this indicates that endotracheal intubation rather than TEE caused the minor complaints. It is concluded that intraoperative TEE can be used without harmful postoperative pharyngeal side effects. Copyright o 1992 by W.B. Saunders Company
inserted orally in all patients at the induction of anesthesia and was removed before extubation. The patients were interviewed and examined again on the morning of the second postoperative day, both the interviewer and patient were unaware of whether TEE had been used. Painful swallowing was estimated using a lo-degree visual analog scale on which 1 denoted no pain and 10 denoted maximal pain.* The results obtained from the visual analog scale were analyzed statistically by means of the nonparametric Mann Whitney U test. Fisher’s exact test was applied to categorical data. Students t test was used to test the difference between the means of the two groups. RESULTS
Of the 57 patients included in the study, 9 could not be examined on the second postoperative day for various reasons. Two patients randomized for TEE were excluded because the probe was difficult to insert into the esophagus on the first attempt; further attempts were abandoned. Seven patients could not be examined because of prolonged ventilator treatment or perioperative death. The second interview and examination were performed on the second postoperative day in 48 patients, 24 of whom had been investigated by TEE during a period of 5.4 2 2.3 hours, and 24 patients who had undergone surgery without TEE. The results for these patients are presented in the Table. Seven patients in the TEE group and two patients in the control group were smokers. There was no difference in total endotracheal intubation time between the TEE and control groups. The score for painful swallowing determined from the visual analog scale did not differ between the groups (TEE, mean 1.8; controls, mean 1.6). There was no difference between groups in time elapsed from extubation to the first oral intake. Two patients in both the TEE and the
From the Department of Cardiothoracic Anaesthetics and Intensive Care, Karolinska Hospital, Stockholm, Sweden. Supported by grants from the Karolinska Hospital, Stockholm, Sweden. Address reprint requests to Anders 6wal1, MD, Department of Cardiothoracic Anaesthetics and Intensive Care, Karolinska Hospital, S-104 01 Stockholm, Sweden. Copyright o I992 by W.B. Saunders Company 1053-0770/92/0601-0004$03.00l0
Journalof Cardiothoracicand VascularAnesthesia, Vol6, No 1 (February), 1992:pp 15-16
15
16
OWALL, STAHL, AND SETTERGREN
Table 1. Complaints on the Second Postoperative Day TEE Group
Age (vrsl
Control
Group
Significance
65.6 t 7.8
60.8 + 9.0
NS
7
2
NS
14.4 + 7.3
12.7 2 6.2
NS
1.8+ 0.9
2.2 2 0.9
NS
Pain during swal-
Mean 1.8,
Mean 1.6.
NS
lowing (score)
range 1-4
range 1-4
Severe postopera-
2
2
NS
Reddened pharynx
2
3
NS
(no.1 Minor injury to lips
3
5
NS
Smokers (no.) Endotracheal
intu-
bation time (hrs) Time from extubation to first oral intake (hrs)
tive nausea (no.)
(no.) Abbreviation:
NS, nonsignificant
control group complained of severe postoperative nausea. Inspection of the oral cavity revealed a reddened pharynx in 2 TEE patients and 3 control patients. Minor injury to the lip was found in 3 TEE patients and 5 control patients. No major complication attributable to the use of TEE occurred. DISCUSSION
The findings of the present study imply that intraoperative TEE can be used during cardiac surgery without harmful pharyngeal side effects in the postoperative period. Minor complaints of sore throat by the patient are common after cardiac surgery using endotracheal intubation and delayed extubation. A sore throat with painful swallowing was not a great problem for the patients in the present
study. The minor complaints that occurred may have been attributable to the endotracheal intubation rather than TEE because no differences were found between the groups. The fact that the evaluation of patient complaints was postponed to the second postoperative day may have influenced the results. An interview at an earlier point in time might have shown more complaints and different findings at the pharyngeal inspection. On the other hand. the patients might have been difficult to examine because of sedation and analgesia. Further, because of the limited number of patients in this study, infrequent pharyngeal complications associated with TEE may remain undetccted. It was difficult to pass the probe into the esophagus in 7 patients in this study. The attending anesthesiologist in one of these cases was inexperienced with TEE, and only one attempt to insert the probe was made. These factors probably contributed to the relatively low success rate.” The interview and examination could not be performed on the second postoperative day in another 7 patients, which may have influenced the results. In the remaining 48 patients. this double-blind study showed no differences between patients who had undergone cardiac surgery with intraoperative TEE and those who had undergone surgery without TEE, regarding patient complaints, painful swallowing, and findings during the oral examination. A recent questionnaire study has demonstrated that TEE also is well tolcrated when performed in the awake unsedated patient.“’ Intraoperative TEE is performed during a period of several hours in patients who do not respond to manipulations ot the probe and who have been anticoagulated and hypothermic during the extracorporeal circulation. Despite these factors, it may be concluded from this study that TEE is well tolerated by the patient during cardiac surgery.
REFERENCES I. Seward HB, Khandheria BK, Oh JK, et al: Transesophageal echocardiography: Technique, anatomic correlations, implementation, and clinical applications. Mayo Clinic Proc 63:649-680,198s 2. Urbanowicz JH, Kernoff RS, Oppenheim G, et al: Transesophageal echocardiography and its potential for esophageal damage. Anesthesiology 72:40-43, 1990 3. Dewhirst WE, Stragand JJ, Fleming BM: Mallory-Weiss tear complicating intraoperative transesophageal echocardiography in a patient undergoing aortic valve replacement. Anesthesiology 731777-778, 1990 4. Cahalan MK, Litt L, Botvinick EH, Schiller NB: Advances in noninvasive cardiovascular imaging: Implications for the anesthesiologist. Anesthesiology 66:356-372, 1987 5. Abel MD, Nishimura RA, Callahan MJ, et al: Evaluation of intraoperative transesophageal two-dimensional echocardiography. Anesthesiology 66:64-68, 1987
6. Geibel A, Kasper ageal echocardiography Am J Cardiol62:337-339.
W, Behroz A, e:t al: Risk of trdnsoesophin awake patients with cardiac diseases. 1988
7. Pearson AC. Castello R, Labovitz AJ: Safety and utility of transesophageal echocardiography in the critically ill patient. Am Heart J 119:1083-1089. 1990 8. Huskisson EC: Visual analogue scales, in Melzack R (ed): Pain Measurement and Assessment. New York, NY, Raven Press, 1983, pp 33-37 9. Daniel WC, Erbel R, Kasper W. et al: Safety of transesophageal echocardiography, a multicenter survey of 10,419 examinations. Circulation 83:817-821. 1991 IO. de Belder MA, Leech MA. Camm AJ: Transesophageal echocardiography in unsedated outpatients: Technique and patient tolerance. J Am Sot Echo 2:375-379, 1989
