Experience of improvised esophageal stethoscope and precordial stethoscope as
effective monitoring tool in developing coun...
An esophageal stethoscope is a simple, versatile, inexpensive monitor that transfer a great
deal of information’s to the b...
audible after inflating the cuff. During operation periodical suction of stomach was given
through endotracheal tube of es...
Findings of the study has been summarized as follows:
• During intraoperative monitoring many a time it has been found tha...
To monitor heart and breathe sound, it has been mentioned in WHO manual that
continuous monitoring of heart rate and respi...
CONCLUSION
Improvised esophageal stethoscope is very simple to assemble, minimally invasive, cost
effective, and properly ...
11. Agnes W, Anil V. Survey of the use of oesophageal and precordial stethoscopes
in current paediatric anaesthetic practi...
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Experience of improvised esophageal stethoscope over precordial stethoscope as effective monitoring tool in developing countries for intraoperative monitoring of children during general anaesthesia. Dr Lt Colonel Abul Kalam Azad

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Experience of improvised esophageal stethoscope over precordial stethoscope as effective monitoring tool in developing countries for intraoperative monitoring of children during general anaesthesia.

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Experience of improvised esophageal stethoscope over precordial stethoscope as effective monitoring tool in developing countries for intraoperative monitoring of children during general anaesthesia. Dr Lt Colonel Abul Kalam Azad

  1. 1. Experience of improvised esophageal stethoscope and precordial stethoscope as effective monitoring tool in developing countries for intraoperative monitoring of children during general anesthesia. ABSTRCT This prospective observational study was carried out to observe effectiveness of improvised esophageal stethoscope over precordial stethoscope. During the study esophageal stethoscope was used to monitor dynamic vital parameters of the children. It has been observed that sometimes heart and breath sounds were not clearly audible by precordial stethoscope due to loose contact and misplacement where as by improvised stethoscope not only heart & breathe sounds but also added & transmitted sounds were clearly audible. Precordial stethoscope needs frequent refixing and repositioning interfering surgical team and sterility where esophageal stethoscope once it is fixed in appropriate depth of insertion position does not change. By esophageal stethoscope even muffle heart sounds can be audible which could minimize stress among anesthesiologists. So, results of the study showed significant difference between precordial and improvised esophageal stethoscope. INTRODUCTION Monitoring of the patient's ventilation and circulation remains of paramount importance during anaesthesia. Simple mechanical devices such as the esophageal stethoscope remain useful both when more sophisticated devices are available and in areas where expensive electronic monitors are not available. Paediatric anaesthesia is a discipline which has particularly utilized monitoring with a stethoscope, either esophageal or external thoracic. Esophageal stethoscopy provides reliable and continuous cardiopulmonary monitoring. The esophageal stethoscope may also provide specialized information such as auditory signs of venous air embolism. The esophageal stethoscope may also allow monitoring when a transthoracic stethoscope may not be practical due to the surgical site.1,2,3
  2. 2. An esophageal stethoscope is a simple, versatile, inexpensive monitor that transfer a great deal of information’s to the brain without expensive high technology.2 Esophageal stethoscope is the best means of monitoring heart sounds, quality of heart tones, in some cases dysrhythmias, murmurs, breath sounds, detect the onset of wheezing, identify secretions that need to be removed by suction and also best means of early detection of venous air embolism.4,5,6,7 An esophageal stethoscope still has a place and that the use of an endotracheal tube placed in the oesophagus is a simple, inexpensive, readily available method which requires minimal expertise to achieve.1,2,3 In developing countries simple, low cost and improvised device is safe, suitable and useful due to unavailability and unaffordability of high cost devices. MATERIALS AND METHODS This prospective observational study was carried out in Dhaka Shishu Hospital among 100 children of ASA grade I & II scheduled for elective surgery under general anaesthesia during the period of Dec 2011 to May 2012. Children with anatomic airway abnormalities, tonsiller hypertrophy, adenoid hypertrophy, bleeding disorder, intracranial hypertension, surgery in esophagus & trachea and porphyria were excluded from the study. During pre-operative assessment height and weight of baby was documented. Procedure was explained to the parents or guardian and informed consent was taken. Children were instructed to fast 6 hours after normal meal and 2 hours after clear liquids before operation. Sisters accompanied the children inside theater, a reliable intravenous access was established and baseline vital parameters were recorded. Experiment was carried out using an improvised esophageal stethoscope assembled by using pediatric sthethoscope without bell & diaphragm and age appropriate sized cuffed endotracheal tube. Lubricated esophageal stethoscope had been inserted through oropharyngeal route into esophagus after administration of GA. Right before insertion of esophageal stethoscope, stomach had been properly suctioned & decompressed and device inserted up to a depth depending on age of the patient where heart and breath sounds were clearly
  3. 3. audible after inflating the cuff. During operation periodical suction of stomach was given through endotracheal tube of esophageal stethoscope. Depth of insertion was also estimated by height in inches divided by two. Quality of heart and breath sounds or any other added sounds has been recorded during intraoperative period. At the end of operation with proper suctioning esophageal stethoscope has been removed before extubation. RESULTS A total 100 patients were included in this study. The study was conducted in Dhaka Shishu Hospital from Dec 2011 to May 2012. The observations obtained in the study have been summarized in tabular form (Table I- II ). Table-I: Age & Sex distribution of children (n=100) Age of the children (Average) Male Female 06 months 25 25 12 months 25 25 Total 50 50 Table-II: Height distribution of children Age of children (Average) Weight (Average) Height (Average) 06 months 7.5 kgs 66.9 cms 12 months 9.8 kgs 75.2 cms Sources: Oxford Medical Publications, 1989
  4. 4. Findings of the study has been summarized as follows: • During intraoperative monitoring many a time it has been found that heart and breath sounds were not clearly audible by thoracic precordial sthethoscope due to loose contact or misplacement but in improvised esophageal stethoscope not only heart and breath sounds are audible but also added & transmitted sounds were clearly audible which helps to take appropriate measures in time. • In thoracic precordial sthethoscope anesthesiologists need to refixed & repositioned the sthethocope frequently, interfering surgical teams and jeopardizing sterility of operations but in esophageal stethoscope once it is fixed in appropriate depth of insertion, position remains as it was like endotracheal tube. • In esophageal stethoscope muffle heart sounds which is audible clearly where peripheral pulse is very weak/ feeble and it minimizes the stress and anxiety among anesthesiologists. DISCUSSION To compare the effectiveness and reliability between improvised esophageal stethoscope and precordial stethoscope for intraoperative monitoring of children during general anesthesia a study was conducted in Dhaka Shishu Hospital. Esophageal stethoscope provides reliable and continuous cardiopulmonary monitoring. The esophageal stethoscope may also provide specialized information such as auditory signs of venous air embolism. The esophageal stethoscope also allow monitoring when a transthoracic stethoscope may not be practical due to the surgical site.1,2,3 In the present study it was observed that during intraoperative monitoring many a time heart and breath sounds were not clearly audible by thoracic precordial sthethoscope due to loose contact or misplacement but in improvised esophageal stethoscope not only heart and breath sounds were audible but also added & transmitted sounds were clearly audible which helps to take appropriate measures in time. The findings is very much consistent to Chakraborty & Mathur study. The findings is also consistent with R N Westhorpe & C Ball study which states that “following induction and intubation, the lubricated catheter is gently inserted into the esophagus. By gentle rotation and an adjustment of catheter depth the point of maximal intensity of heart sounds, murmurs or breath sounds maybe determined.8,9,10”
  5. 5. To monitor heart and breathe sound, it has been mentioned in WHO manual that continuous monitoring of heart rate and respiration is essential in small children in which a precordial or oesophageal stethoscope suggested as invaluable tool for monitoring.17 In our study it was clearly differentiated the effectiveness and reliability of two devices. Esophageal stethoscope even muffle heart sounds were audible clearly where peripheral pulse was very weak/feeble and it minimizes the stress and anxiety among anesthesiologists where as precordial stethoscope was less effective as a monitoring tool. In thoracic precordial sthethoscope anesthesiologists need to refixed & repositioned the sthethocope frequently, interfering surgical teams and jeopardizing sterility of operations but in esophageal stethoscope once it is fixed in appropriate depth of insertion, position remains as it is like endotracheal tube. Teaching about and routine use of a precordial or esophageal stethoscope was not deemed essential by majority of existing residency programs. A reevaluation of this lack of education appears warranted in light of the low cost and extra added patient vigilance provided by the precordial or esophageal stethoscope.13,14,15,16 There was another study where it has also been states that current anesthesia training may be fostering an environment where providers overlook a valuable minimally invasive, and cost-effective continuous monitor of patients' dynamic vital organ function.12 In the present observational study it was suggested that although anesthesia provider is overlooking this simple but effective device, though it couldn’t be enlisted into anesthesia curriculum but this device is providing direct information to anesthesia providers without delay which is inevitable in modern monitoring equipments because all monitoring equipment having response time before providing information to anesthesia providers. There were limitations of our study like tracheal tube is designed for trachea not for esophagus, so stomach content might regurgitate back. To date there is no PVC tube designed for esophagus with a blind tip for esophageal use. There is no such study that inflation of cuff cause esophageal ischemia. There is lack of similar study to get data and book pictures of improvised esophageal stethoscope which is consistent with Dr Agnes Watson study.11 .
  6. 6. CONCLUSION Improvised esophageal stethoscope is very simple to assemble, minimally invasive, cost effective, and properly suitable for developing countries which provides continuous monitoring of dynamic vital organ functions. The use of the stethoscope as a continuous monitoring device has decreased among training institutions and most anaesthesiologists feel it has been superseded by other monitoring equipments although the complications of these monitoring devices were rare. The main factors limiting the use of stethoscope are due to the presence of modern monitoring equipments such as pulse oximetry and capnography. References: 1. Chakroborty A, Mathur S. A simple technique for esophageal stethoscopy. Anaesthesia and Intensive Care 2007; 2. Eckhardt K, Aseno S. The individually fitted earpiece. Letter to the editor. Update in Anaesthesia 2002; 14:33. 3. Manecke Jr GR, Poppers PJ.Esophageal stethoscope placement depth: its effect on heart and lung sound monitoring during general anesthesia. Anesth Analg 1998; 86:1276-1279. 4. Petty C. We do need precordial and esophageal stethoscopes. 1987,3:192-193 5. Mayer BW. Pediatric anesthesia; a guide to its administration; Philadelphia, Lippincott, 1981:34-35 6. Karl E, Samuel A. Update in Anaesthesia 2002;14:13 7. Anaesthesia in the District Hospital. World Health Organisation 2001 8. McIntyre JWR. Stethoscopy during anaesthesia. Can J Anaesth 1997; 44:535-542. 9. Westhorpe R N, Ball C. Precordial and oesophageal stethoscopes. Anaesthesia and Intensive Care 2008; 10. Smith C. An endo-esophageal stethoscope. Anesthesiology 1954; 15:566.
  7. 7. 11. Agnes W, Anil V. Survey of the use of oesophageal and precordial stethoscopes in current paediatric anaesthetic practice 2001; 11:437-442 12. Richard C, Jeffrey S. Use of esophageal or precordial stethoscopes by anesthesia providers: Are we listening to our patients? Journal of Clinical Anesthesia 1995,7:367-372 13. Alan Jay S. The Precordial/Esophageal Stethoscope-A Vigilance Monitor No Longer Taught to Anesthesiology Residents. Anesthesiology 2001; 95:A524 14. Gregory GA: Monitoring During Surgery in PEDIATRIC ANESTHESIA, 2nd ed, Gregory GA, ed, NY, Churchill Livingstone, 1989, pp 478. 15. Raemer DB: Monitoring Respiratory Function in PRINCIPLES AND PRACTICE OF ANESTHESIOLOGY, Rogers MC, Tinker JH, Covino BC, Longnecker DE eds, St Louis, Mosby Year Book, 1993, pp 783. 16. http://www.health.state.ny.us/ (Section 405.13). 17. WHO manual. Essential surgical care.

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