Abstract
Purpose
To describe a case of a massive gastric bleeding following emergency coronary artery bypass surgery associated with transoesophageal echocardiographic (TEE) examination.
Clinical features
A 50-yr-old man was referred for an acute myocardial infarction and pulmonary edema (Killip class 3). Twelve hours after his myocardial infarction, he was still having chest pain despite aniv heparin infusion. Coronary angiography revealed severe three-vessel disease with multifocal stenosis of the left anterior descending, circumflex and total occlusion of the right coronary artery. The patient was transferred to the operating room for emergency coronary artery bypass graft surgery. After total systemic heparinization (3 mg·kg−1) was obtained for cardiopulmonary bypass, a multiplane TEE probe was inserted without difficulty to monitor myocardial contractility during weaning from CPB. During sternal closure, the TEE probe was removed and an orogastric tube was inserted with immediate drainage of 1,200 ml red blood. Endoscopic examination demonstrated a mucosal tear near the gastro-oesophageal junction and multiple erosions were seen in the oesophagus. These lesions were succesfully treated with submucosal epinephrine injections and the patient was discharged from the hospital eight days after surgery.
Conclusion
This is a report of severe gastrointestinal hemorrhage following TEE examination in a fully heparinized patient. This incident suggest that, if the use of TEE is expected, the probe should preferably be inserted before the administration of heparin and the beginning of CPB.
Résumé
Objectif
Décrire un cas de gastrorragie survenue après un pontage aortocoronarien et associée à un examen par échocardiographie transoesophagienne (ETO).
Aspects cliniques
Un homme de 50 ans a été admis à l’hôpital pour un infarctus aigu du myocarde et un oedème pulmonaire (classification de Killip : 3). Douze heures après l’infarctus, il éprouvait toujours des douleurs thoraciques malgré une perfusion intraveineuse d’héparine. La coronarographie a montré une maladie tritronculaire sévère qui se manifestait par une sténose multifocale de l’artère interventriculaire antérieure, de l’artère auriculo-ventriculaire et l’occlusion totale de l’artère coronaire droite. Le patient a été transporté à la salle d’opération pour un pontage aortocoronarien d’urgence. Après que l’héparinisation générale totale (3 mg·kg−1) a été obtenue pour la circulation extracorporelle, une sonde d’ETO multiplan a été facilement introduite pour contrôler la contractilité du myocarde pendant le sevrage de la CEC. Pendant la fermeture stemale, on a retiré la sonde d’ETO et on a inséré un tube orogastrique pour un drainage immédiat de 1200 ml de sang rouge. Lexamen endoscopique a démontré une dilacération près de la jonction oeso-gastrique et de multiples érosions ont été visualisées dans l’oesophage. Ces lésions ont été traitées avec succès par des injections sous-muqueuses d’épinéphrine et le patient a quitté l’hôpital huit jours après la chirurgie.
Conclusion
Nous avons rapporté le cas d’une hémorragie gastro-intestinale sévère survenu à la suite d’une ETO chez un patient complètement héparinisé. Cet incident permet de présumer que, dans le cas où on pense utiliser l’ETO, la sonde devrait, de préférence, être introduite avant l’administration d’héparine et le début de la CEC.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Poterack KA. Who uses transesophageal echocardiography in the operating room? Anesth Analg 1995; 80: 454–8.
Daniel WG, Erbel R, Kasper W, et al. Safety of transesophageal echocardiograhy. A multicenter survey of 10,419 examinations. Circulation 1991; 83: 817–21.
Savino JS, Hanson CW, Bigelow DC, Cheung AT, Weiss SJ. Oropharyngeal injury after transesophageal echocardiography. J Cardiothorac Vasc Anesth 1994; 8: 76–8.
Latham P, Hodgins LR. A gastric laceration after transesophageal echocardiography in a patient undergoing aortic valve replacement. Anesth Analg 1995; 81: 641–2.
Dewhirst WE, Stragand JJ, Fleming BM, Mallory-Weiss tear complicating intraoperative transesophageal echocardiography in a patient undergoing aortic valve replacement. Anesthesiology 1990; 73: 777–8.
Spahn DR, Schmid S, Carrel T, Pasch T, Schmid ER. Hypopharynx perforation by a transesophageal echocardiography probe. Anesthesiology 1995; 82: 581–3.
Kharasch ED, Sivamjan M. Gastroesophageal perforation after intraoperative transesophageal echocardiography. Anesthesiology 1996; 85: 426–8.
Norton ID, Pokorny CS, Baird DK, Selby WS. Upper gastrointestinal haemorrhage following coronary artery bypass grafting. Aust NZ J Med 1995; 25: 297–301.
Leitman IM, Paull DE, Barie PS, Isom OW, Shires GT. Intra-abdominal complications of cardiopulmonary bypass operations. Surg Gynecol Obstet 1987; 165: 251–4.
Hulyalkar AR, Ayd JD. Low risk of gastroesophageal injury associated with transesophageal echocardiography during cardiac surgery. J Cardiothorac Vasc Anesth 1993; 7: 175–7.
Maurer G, Share E. Intubation of the upper gastrointestinal tract: methodological, anatomical, and safety considerations. In:Maurer G (Ed.). Transesophageal Echocardiography. New York: McGraw-Hill Inc., 1994: 25–40.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
St-Pierre, J., Fortier, LP., Couture, P. et al. Massive gastrointestinal hemorrhage after transoesophageal echocardiography probe insertion. Can J Anaesth 45, 1196–1199 (1998). https://doi.org/10.1007/BF03012463
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03012463