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(Chest. 2001;119:319.)
© 2001 American College of Chest Physicians

Placement of the Esophageal Doppler Ultrasound Monitor Probe in Awake Patients

Glen Atlas, MD, MSc and Thomas Mort, MD

Hartford Hospital University of Connecticut School of Medicine Hartford, CT

Correspondence to: Glen Atlas, MD, MSc, Departments of Anesthesiology and Surgical Critical Care, Hartford Hospital/University of Connecticut School of Medicine, 80 Seymour St, Hartford, CT 06102-5037; e-mail: gatlas{at}harthosp.org

To the Editor:

By anesthetizing the nasal mucosa, the esophageal Doppler ultrasound monitor (EDM) probe can be readily inserted into awake patients. The advantages of this minimally invasive tool to accurately and quickly ascertain cardiac contractility, aortic flow, and preload are well established.1 2 3 In addition, these indexes are determined on a continuous basis. Thus, there is tremendous utility for this device in critically ill patients who are awake or sedated, including those in the operating room, intensive care or "step-down" units, or postanesthesia care unit.

Initially, the patient’s coagulation status must be examined. With nasal insertion of the EDM probe, anticoagulation could lead to significant nasal bleeding. The presence of nasal polyps may also predispose to bleeding. Furthermore, patients with facial or basilar skull fractures should be carefully evaluated prior to placement of any nasal device.

The significance of a deviated septum can be assessed by having the patient breathe while manually occluding each nostril individually. Accordingly, the nostril with the greatest patency should be used for probe placement.

Following this, nasal vasoconstrictors, such as oxymetazoline or phenylephrine, may be applied by spray. Topically placed cocaine, which produces both vasoconstriction and local anesthesia, can also be used.4 However, the hemodynamic effects of cocaine may limit its use.

The turbinates may be dilated by use of a nasal airway.5 Topical 2% lidocaine gel applied to the nasal airway will act as both a lubricant and anesthetic. Use of sequentially larger diameter nasal airways may be necessary to achieve adequate dilation. Each nasal airway should be left in place for several minutes before proceeding.

The posterior oropharynx can be sprayed with benzocaine or a similar aerosol-based local anesthetic. Having the patient swallow then allows for additional oropharyngeal and esophageal anesthesia.

The proximal aspect of the EDM probe should also be coated with lidocaine gel before insertion. If necessary, small amounts of benzodiazepines and/or opiates may useful for increasing patient tolerance.

Using this technique, the EDM probe has been reliably placed in awake patients for up to several hours. Subsequent manipulation of the EDM probe is also well tolerated.

References

  1. Singer, M (1993) Esophageal Doppler monitoring of aortic blood flow: beat by beat cardiac output monitoring. Int Anesthesiol Clin 31,99-125[ISI][Medline]
  2. Madan, AK, UyBarreta, VV, Aliabadi-Wahle, S, et al (1999) Esophageal Doppler ultrasound monitor versus pulmonary artery catheter in the hemodynamic management of critically ill surgical patients. J Trauma 46,607-612[ISI][Medline]
  3. Marik, PE (1999) Pulmonary artery catheterization and esophageal Doppler monitoring in the ICU. Chest 116,1085-1091[Abstract/Free Full Text]
  4. Gross, JB, Hartigan, ML, Schaffer, DW (1984) A suitable substitute for 4% cocaine before blind nasotracheal intubation: 3% lidocaine-0.25% phenylephrine nasal spray Anesth Analg 63,915-918[Abstract/Free Full Text]
  5. Dow, A (1993) Regional anesthesia. Grande, CM eds. Textbook of trauma anesthesia and critical care ,486-487 Mosby (St. Louis, MO).




This Article
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Right arrow Similar articles in ISI Web of Science
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Right arrow Articles by Mort, T.

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