Accidental cut of esophageal temperature probe during lobectomy for lung cancer - A case report -

Abstract

Adequate maintenance of body temperature during general anesthesia is necessary for patients' safety. Perioperative thermal disturbance can cause numerous adverse outcomes such as wound infection, coagulopathy, delayed postanesthetic recovery, and prolonged hospitalization [1][2][3]. Core temperature can be accurately monitored at the tympanic membrane, distal esophagus, nasopharynx, and pulmonary artery [4]. Generally, esophageal temperature probe is used because of its reliability [5] and feasibility in practice. Liu et al. [6] suggested that esophageal temperature is more reliable than tympanic temperature during thoracotomy. Proper placement of esophageal temperature probe is important to avoid unwanted complications: inadvertent temperature reading, airway irritation, and serious hypoxemia [7][8][9].Herein, we reported a rare complication involving esophageal temperature probe which was misplaced into the right intermediate bronchus and accidentally cut in a patient undergoing lobectomy of the lung. CASE REPORTA 79-year-old man (height 163 cm, body weight 63 kg) was scheduled to undergo middle and lower bilobectomy of the right lung through video-assisted thoracic surgery. The patient was diagnosed with adenocarcinoma of the right middle lobe. Chest radiographic examination before surgery revealed a 3-cm sized mass-like lesion at the right middle lobe bronchus with distal segmental atelectasis; pulmonary function test showed normal results; and systemic positron emission computed tomography showed no metastasis except in the right lung.On entrance into the operation room, patients' intraarterial blood pressure, electrocardiography, pulse oximetry, end-tidal CO 2 , and central venous pressure were monitored.Temperature of the operation room was set at 25°C and breathing circuit was automatically heated and humidified.After induction with propofol and remifentanil through target-controlled infusion, the trachea was intubated with 37 Fr

Airway leakage due to malpositioning of esophageal temperature probe during robot-assisted radical prostatectomy: a case report

“…Although there were no ventilation-related problems, the patient's body temperature did not rise above 36.2 C, and tracheal insertion of the temperature probe was recognized through a routinely performed portable chest X-ray examination after surgery. Lee et al 9 and Dabbous et al 10 reported similar cases involving patients who underwent lobectomy. No abnormalities in ventilation or body temperature occurred during surgery, but part of the temperature probe was found in the resected lung, and tracheal insertion of the temperature probe was thus recognized.…”

“…5 Previous case reports have described inadvertent tracheal insertion of esophageal temperature probes during surgeries. [6][7][8][9][10] In two of these case reports, the patients developed abnormal ventilation. 6,7 In another report, the patient maintained normal ventilation but had an abnormally low body temperature measurement.…”

“…8 In two other cases, the patients maintained normal ventilation and normothermia; however, part of the temperature probe was found after lung resection, indicating that the temperature probe had been placed into a bronchus. 9,10 We herein report a case involving the malpositioning of an esophageal temperature probe in the right inferior lobar bronchus. The patient's ventilation became impaired when we applied the steep Trendelenburg position and positive end-expiratory pressure (PEEP) for robot-assisted radical prostatectomy (RARP).…”

Concordance of esophageal and tracheal temperatures in patients using breathing circuit with heated wire humidifier: A prospective observational study

“…[ 14 , 15 ] Lee et al reported a case wherein a malpositioned esophageal temperature probe in the right intermediate bronchus was accidentally cut during lung lobectomy. [ 28 ] Moreover, esophageal temperature probes cannot be inserted during surgeries that require an intraoral approach or esophageal manipulation. Tracheal temperature monitoring is convenient in such cases as temperature monitoring can be started immediately after intubation, and the insertion of another temperature probe is not necessary.…”

Comparison of upper and lower body forced air blanket to prevent perioperative hypothermia in patients who underwent spinal surgery in prone position: a randomized controlled trial

“…In this study, we used the nasopharyngeal temperatures as intraoperative core temperature; the nasopharyngeal temperature is more reliable compared with bladder temperature, because bladder temperature is strongly influenced by urine flow [15,16]. And, the esophageal probe are at risk of misplacement due to relatively long distance from incisor (approximately 40 cm) compared to nasopharyngeal probe [13,[17][18][19]. However, the distance between the upper body blankets to nasopharynx is closer compared with lower body blanket, and it might raise nasopharyngeal temperature more quickly, even though head was not covered with the upper body blanket in our study.…”