University of Connecticut School of Medicine
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: firstname.lastname@example.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.1–3 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
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
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
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
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.
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