Complications From Operator Modification of the Esophageal Temperature Probe.

Intraoperative temperature monitoring of surgical patients is an important aspect of perioperative care. Central core temperature monitoring is often accomplished using an 18 French esophageal device inserted through the mouth into the esophagus, while patients are undergoing general anesthesia. Placement of a modified esophageal temperature probe (i.e. with the protective plastic covering removed) into the nasopharynx of a patient may cause significant patient harm by injuring the nasal mucosa and/or turbinates. An internal survey of current practice at our academic institution reveals that 78% of anesthesia providers modify the esophageal temperature probes, leading to an 11% injury incidence. A practical solution to avoid complications is to place a pediatric size 9 French esophageal temperature probe into the nasopharynx to monitor the central core temperature.