Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 127-129
The twisty tube chronicle: When in doubt, take it out!

1 Department of Anaesthesia, Nawaloka Hospitals, No 23, Deshmanya H. K. Dharmadasa Mw. Colombo, Sri Lanka, India
2 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS) Raipur, Chhatisgarh, India

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Date of Submission19-Dec-2021
Date of Acceptance19-Dec-2021
Date of Web Publication21-Jan-2022

How to cite this article:
Waikar HD, Neema PK. The twisty tube chronicle: When in doubt, take it out!. Ann Card Anaesth 2022;25:127-9

How to cite this URL:
Waikar HD, Neema PK. The twisty tube chronicle: When in doubt, take it out!. Ann Card Anaesth [serial online] 2022 [cited 2022 Oct 1];25:127-9. Available from:

To the editor,

Transesophageal echocardiography (TEE) has become an essential tool to diagnose and monitor cardiac function and to assess the severity of underlying disease, hemodynamic parameters, and effectiveness of pharmacological interventions. In general, TEE is an integral intraoperative monitoring device in cardiac as well as high-risk noncardiac surgical procedures. Its safety has been evaluated by many authors and it is considered safe and noninvasive. The reported risk of morbidity in cardiac surgical patients ranges from 0.05% to 1.2%, and the risk of mortality is 0.02%.[1] Broadly the complications can be divided into gastrointestinal and respiratory complications. Injuries to the gastrointestinal tract, rupture of esophageal varices, and trauma to solid organs and oral cavity have been reported. Dysphagia is a common complication reported in 4% of patients and odynophagia in 0.1%. GI bleed, melena, Mallory–Weiss tear, and accidental puncture or laceration are the reported complications related to probe insertion. Bilateral vocal cord palsy, injury to larynx, dysphonia are also reported.[2] Accidental extubation of endotracheal (ET) tube, obstruction to ET tube or displacement of ET tube in children can be disastrous.[3]

Multivessel off-pump coronary artery bypass grafting was performed in a 68-year-old male patient. Briefly, anesthesia was induced with etomidate 8 mg, xylocard 100 mg, midazolam 5 mg, and fentanyl 150 μg. Tracheal intubation with an 8 mm ID cuffed ET tube (Portex, Smith Medical International Ltd. Hyeth, Kent, UK) was facilitated using 100 mg succinylcholine for muscle relaxation. The ET tube was fixed at 23 cm mark at lip level. Anesthesia was maintained with N2O, oxygen, fentanyl, and sevoflurane and muscle relaxation was maintained with intermittent boluses of pancuronium/vecuronium bromide. Apart from standard ASA monitors, TEE probe was inserted with the help of laryngoscope for cardiac function monitoring. The laryngoscope was used to displace the tongue toward left to create space for TEE probe insertion and care was taken to ensure that the tip of the laryngoscope does not press upon the ET tube. The surgery lasted 4 hours. The patient was electively ventilated in cardiac surgical intensive care unit with propofol infusion (150 mg/h) and morphine 2 mg/h. Tidal volume was 8 ml/kg; peak inspiratory pressure (PIP) alarm limit was set at 35 cm water. Arterial blood gases on FiO2 0.4 were satisfactory. The patient remained hemodynamically stable and no inotrope was required. About 6 hours later, a fall in SpO2 from 100% to 85% occurred. FiO2 was increased to 0.6, but there was no increase in SpO2. The PIP increased to 55 cm of water, Ambu bag ventilation was difficult, and air entry was considerably reduced bilaterally. A 14 F suction catheter was passed down the ET tube but could not be passed. The ET tube was removed immediately and the trachea was reintubated with a 7.5 mm ET tube (Portex Tube). PIP, and bilateral air entry became normal and trachea was successfully extubated 2 hours later. On close inspection of the ET tube, a kink was noted at 17 cm mark [Figure 1]. The 17 cm mark on the ET tube corresponded to the oropharyngeal portion of the TEE probe; we believe that the TEE probe compressed the ET tube in oropharynx during surgery which caused a conformational change in the ET tube due to its softening at body temperature; however, the lumen remained uncompromised. In the ICU, while nursing in a supine position with a head-up position, the weakened portion of ET tube kinked acutely over a period of time and resulted in near-total obstruction and respiratory compromise. The rise in PIP and fall in SpO2 can occur with severe bronchospasm and tension pneumothorax; however, there were no rhonchi on auscultation and both the pleura were widely opened with intercostal drains in situ. This case highlights another critical complication because of a TEE probe.
Figure 1: Shows kink at 19 cm mark

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Purza R, Ghosh S, Walker C, Hiebert B, Lilian K, Mackenzie GS, et al. Transesophageal echocardiography complications in adult cardiac surgery: A retrospective cohort study. Ann Thorac Surg 2017;103:795-803.  Back to cited text no. 1
Mathur SK, Singh P. Transesophageal echocardiography related complications. Indian J Anaesth 2009;53:567-74.  Back to cited text no. 2
[PUBMED]  [Full text]  
Neema PK, Sethuraman M, Vijaykumar A, Misra S, Rathod RC. Resolution of airway compression induced by transesophageal echocardiography probe insertion in a paediatric patient after repair of an atrial septal defect and partial anomalous pulmonary venous connection: Possible mechanisms. J Cardiothorac Vasc Anesth 2007;22:887-9.  Back to cited text no. 3

Correspondence Address:
Hemant D Waikar
Chief Cardiac Anaesthetist, Nawaloka Hospitals, No 23, Deshmanya H. K. Dharmadasa Mw. Colombo 00200, Sri Lanka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.aca_195_21

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