We describe a case of a 72-yr-old male who suffered aerodigestive tract chemical injury resulting from a probable post-processing residual of the high-level disinfectant solution Cidex OPA (ortho-phthalaldehyde) used to disinfect the transesophageal echocardiogram probe used for cardiac monitoring during general anesthesia. This case highlights the need for strict adherence to manufacturers' instructions when using chemical disinfectants for transesophageal echocardiogram probe reprocessing.
Implications: We describe a case of aerodigestive tract chemical injury resulting from a probable post-processing residual of the high level disinfectant solution Cidex OPA (ortho-phthalaldehyde) used to disinfect the transesophageal echocardiogram probe used during general anesthesia.