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• W4256685651 abstract "Although pulse oximetry has become a standard of care in anesthesia monitoring, surface (finger) probe monitoring is sometimes unreliable when perfusion is poor [1]. Pulse oximetry data failure rates based on a review of computerized records reveal gaps in signal acquisition (defined as a continuous loss of pulse oximetry >or=to10 minutes) [2]. I report a case in which a newly developed transesophageal pulse oximetry (ESOX) system provided continuous monitoring of the hemoglobin saturation with oxygen (SpO2) at a time when surface pulse oximetry was unobtainable, probably as a result of poor peripheral perfusion. Case Report An 89-yr-old woman with a history of peripheral vascular disease and multiple previous vascular surgical procedures presented with occlusion of her left femoral posterior tibial bypass graft. Her medical history included paroxysmal supraventricular tachycardia, hypertension, and congestive heart failure. Her medications included digoxin, furosemide, enalapril, metoprolol, and clonidine. She underwent femoral-tibial bypass grafting under epidural anesthesia with intravenous sedation. Five hours post-operatively, the patient was bleeding from the distal (tibial) anastomosis (estimated 200 mL blood loss) and was returned to the operating room for exploration and hemostasis under general anesthesia. After application of the monitors, peripheral pulse oximetry readings (Ohmeda 3710; BOC Healthcare, West Yorkshire, UK) were difficult to obtain, but they indicated an SpO (2) of 98%. General anesthesia was induced with thiopental and succinylcholine and was maintained with fentanyl, pancuronium, and isoflurane. After induction of anesthesia, peripheral pulse oximetry readings were unobtainable and remained so for the 60-min duration of the anesthetic, despite movement of the disposable fingertip probe to other fingers. Esophageal temperature was 35.2[degree sign]C. Arterial blood pressure was 150/70 mm Hg was obtained using the arterial line before induction of anesthesia and decreased to 100-120 mm Hg (systolic arterial pressure) after induction. An arterial blood gas (ABG) determination after induction of anesthesia revealed pH 7.35, PacO2 20 mm Hg, PaO2 120, and SaO2 98.5%; hemoglobin was 11.0 g/dL. Postinduction hypotension was treated with two 50-micro g boluses of phenylephrine and intravenous fluid administration. Despite the return of preoperative blood pressure, with good urine output and a temperature of 35.3[degree sign]C, the patient's surface pulse oximetry (fingertip and earlobe) failed to yield an SpO2 value. A transesophageal pulse oximeter (ESOX) probe (Figure 1) (ARISTO Medical, Waukesha, WI) was inserted until the oximetry element was past (inferior to) the cricoid cartilage. The device was withdrawn until the cricopharyngeus muscle secured the device in place by surrounding the narrow central portion of the probe. The resulting locked position, with the cricopharyngeus muscle between the bulges of the probe (Figure 2), provided secure juxtaposition of the probe with the esophageal mucosa and pharyngeal constrictors, thereby minimizing motion artifact. The final probe position was 13 cm from the lower alveolar ridge. This position provided auscultation of heart and breath sounds as well as esophageal temperature monitoring (inferior to the ESOX probe). A pulsatile signal corresponding in rate to that of the electrocardiogram was obtained, with an SpO2 recording of 98%, correlating with the SaO2 obtained from the ABG noted above. The patient was returned to the intensive care unit (ICU) with stable vital signs and a temperature of 35.3[degree sign]C. An ABG determination on arrival in the ICU revealed pH 7.37, PacO2 of 29 mm Hg, and PaO2 199 mm Hg. As the patient awakened in the ICU, the peripheral pulse oximetry once again became obtainable. The patient was extubated 12 h after the procedure and experienced an uneventful postoperative course.Figure 1: Photograph of the transesophageal pulse oximeter (with auscultation and temperature monitoring capability) used in this case.Figure 2: Illustration depicting the transesophageal pulse oximeter in the locked position at the level of the cricopharyngeus muscle, which inserts at the cricoid cartilage.Discussion We are not aware of any previous case report of the successful use of transesophageal pulse oximetry during anesthesia while peripheral pulse oximetry was unobtainable. The ESOX probe used during this case was developed by Atlee et al. [3]. They found the optimal sensor orientation to be transverse rather than longitudinal. They also established the similarity of SpO2 values in surface and transesophageal monitoring sites in patients receiving general endotracheal anesthesia [3]. The ESOX probe relies on unique reflectance oximetry technology [4], in contrast with the absorption oximetry used for peripheral oximetry. The probe design also provides for temperature monitoring and auscultation of heart and breath sounds. Atlee and Brunson [5] reported that surface and esophageal pulse oximetry values are comparable in dogs subjected to desaturation and hypotension. Dhamee et al. [6] compared ESOX SpO2 measurements with simultaneous SaO2 measurements (IL482 co-oximeter) during clinical desaturation of a patient with alveolar proteinosis undergoing pulmonary lavage. They found comparable, favorable trending during transient desaturations to SaO2 values as low as 70%. Freund et al. [7] defined pulse oximetry failure as the inability to obtain a reading for 30 minutes after a variety of alternative sites had been tried and mechanical problems had been eliminated. They reported a 1.12% failure rate of peripheral pulse oximetry in 11,046 anesthetic procedures at the University of Washington Hospitals. In their report, Reich et al. [2] noted that the failure rate of surface pulse oximetry (defined as at least one continuous gap of >or=to10 minutes in pulse oximetry data) was 11% for vascular surgical procedures; this was the highest failure rate of all noncardiopulmonary bypass procedures. It is therefore not unusual that difficulty was encountered in obtaining a surface oximetry signal in our patient with long-standing peripheral vascular disease. Kidd and Vickers [8] suggest that hypotension with vasoconstriction causes a reduction in the pulsatile component of the plethysmographic wave form generated by the pulse oximetry probe, which consists of two photodiodes: one producing red and the other infrared light, and a single photodetector. Because only the pulsatile component of the wave form (1%-5% of each signal) is processed, reducing the pulsatile component would lead to failure of the pulse oximetry system to determine an accurate SpO2 value. Our case supports the suggestion of Atlee and Bratanow [3] that the esophagus, a core organ, is better perfused than the extremities during states of poor peripheral perfusion and that therefore it provides a more consistent, reliable source for pulse oximetry. Prielipp et al. [4] have compared ESOX with peripheral pulse oximetry during coronary artery bypass grafting. Using computerized data acquisition from the oximeters, they determined that the peripheral oximeters acquired and displayed saturation signals more often than the ESOX unit, but they attribute this difference to electrocautery interference during intrathoracic procedures. They observed that the ESOX signal was sometimes well preserved when the peripheral sensors failed, and they suggested that the esophagus may represent an improved pulse oximetry monitoring site during anesthesia. The ESOX device in its present design does have some limitations. In our experience (unreported data in 30 patients), accurate placement of the ESOX probe requires practice by the user. We share the theory of Prielipp et al. [4] that interference by surgical electrocautery may be more pronounced with the ESOX system than with peripheral pulse oximetry. Improved electrocautery shielding and modified software may contribute to the solution of this problem. In conclusion, a recently developed esophageal pulse oximetry device made an important contribution to the intraoperative monitoring of a patient with poor peripheral perfusion. The author gratefully acknowledges the assistance of Ellen Park (Medical Illustration, Scott & White Hospital) and Lisa Elliott Blaschke (Publications, Scott & White Hospital) in the preparation of this manuscript." @default.
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• W4256685651 date "1997-09-01" @default.
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• W4256685651 title "The Successful Use of Transesophageal Pulse Oximetry in a Patient in Whom Peripheral Pulse Oximetry Was Unobtainable" @default.
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