Post-Operative Chapters 17 and 18

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: Vasanthi.vidyasagaran@gmail.com

Dr. Vasanthy Vidyasagaran Muralidharan

POST-OPERATIVE  – Chapter 17

Pneumothorax following Removal of Sharp FB in Airway

A 2-year-old child weighing 14 kg was admitted with history of possible foreign body (FB) in the airway with recurrent bouts of coughing. He was feeding poorly since then. He was seen by a paediatrician and referred to the ENT department. On examination, he looked reasonably well. Chest auscultation revealed no crepitations or wheeze. He was not dyspnoeic, however there was incessant coughing and excessive oral secretions suggestive of FB in the airway.

Chest x-ray was requested. It showed a foreign body– an open safety pin in the bronchus. The child was posted for bronchoscopy and foreign body extraction under general anaesthesia. Preoperatively, it was ensured that the baby was starved for six hours, prepared with steroid and bronchodilator nebulisers and IV Dexamethasone 4 mg. Single dose of antibiotic cover was given.

On table, anaesthesia was induced with Propofol, and Suxamethonium was used for muscle relaxation. No positive pressure ventilation was given at this point. Surgeon introduced the rigid bronchoscope to visualize the airway. Oxygen was administered via the side port and high frequency ventilation was provided. Surgeon picked up the open pin with his instrument, however manipulation and removal of the open pin was challenging and took time, as the open pin would not enter the lumen of the scope.

On the third attempt, the surgeon managed to pull out the pin with some difficulty as it was getting caught at the level of the glottis. The concerns at this stage was damage to the tracheal mucosa, and/or the vocal cords. In the meantime, oxygenation was maintained by the anaesthetic team. Following the removal of the foreign body, patient was ventilated via bag and mask. Oxygen saturations were normal and patient was stable. There were no immediate signs of any respiratory distress.

Respiratory support was withdrawn after the child commenced breathing and maintained airway on his own. However, in the recovery room, he became dyspnoeic and tachypnoeic. Oxygen was administered at 6 L/min, but the saturation kept fluctuating and eventually started dropping to 94%. Auscultation revealed diminished breath sounds on the right side and the child was restless. Emergency chest x-ray was requested.

Chest x-ray revealed pneumothorax on the right side. Air was let out by using 20 size intracath (venflon) and definitive chest drain was placed by the paediatric team. The child was sedated and kept comfortable and stable during this period. He recovered well with no further complications.

Discussion

This was a case of pneumothorax following removal of a sharp foreign body in the trachea. Manipulation of the sharp object was not easy and had caused tracheal wall damage. In due course of time, with positive pressure ventilation administered, the air leak had become significant enough to cause a pneumothorax that required drainage.

Literature evidence suggests that such events are not uncommon and risks involved with these procedures must be discussed with family beforehand. Complications such as bleeding, loss of airway, pneumothorax (unilateral or bilateral) can even be fatal. The procedure may sound simple and short, but may have catastrophic consequences. Hence, they must be dealt with great caution, anticipating problems and being alert. Recognition and immediate management saves lives.

References

  • Hussain S, Khan RA, Iqbal M. Tension pneumothorax caused by ventilating rigid bronchoscopy for removal of foreign body. Anaesth Pain & Intensive Care 2011; 15(1):57-59.
  • Harar RP, Pratap R, Chadha N, Tolley N. Bilateral tension pneumothorax following rigid bronchoscopy: a report of an epignathus in a newborn delivered by the EXIT procedure with a fatal outcome. J Laryngol Otol. 2005; 119:400-402.
  • Gallagher MJ, Muller BJ. Tension pneumothorax during pediatric bronchoscopy. Anesthesiology. 1981; 55:685-686.
  • Rothmann BF, Boeckman CR. Foreign bodies in the larynx and tracheobronchial tree in children: a review of 225 cases. Ann Otol Rhino Laryngol. 1980; 89:434-t436.

 

POST-OPERATIVE  – Chapter 18

Poor Vision following Laparoscopic Hysterectomy – an ‘Eye Opener’

A 55-year-old patient with moderate hypertension, on treatment with Losartan and Atenolol was posted for a laparoscopic hysterectomy under routine GA with endotracheal intubation. Atenolol was continued and Losartan was stopped 1 day prior to surgery.

The surgery lasted two and a half hours. The patient’s haemodynamics were stable throughout the

procedure. Recovery was uneventful; she regained consciousness and muscle power and was extubated.

After extubation, she became extremely restless and began complaining that she was unable to see. Her vision continued to be blurred even after half an hour of observation. She also complained of headache. It was considered to be a case of raised ICT, due to steep head down tilt and pneumoperitoneum. 40 mg Lasix and 100 ml 20% Mannitol were administered. She felt a little better but her vision did not improve, and she still could not see clearly.

An ophthalmic referral was called for, and it was diagnosed to be a case of pre-existing glaucoma, which was made worse by the position and fluid administration. On probing further, she gave a family history of glaucoma and was herself due for an ophthalmic consultation as she had some difficulty with her vision, but postponed it.

It is not routine practice to enquire about glaucoma or any other ophthalmic condition in our preoperative work up. But information regarding medication for any underlying condition should be sought for.

This case was actually an ‘eye opener’!

Discussion

There is an increasing trend of laparoscopic surgery being performed in aging population. But ophthalmic complaints/conditions and any history of medications are not given their due importance and must be ‘viewed’ seriously. Several drugs which can interact with anaesthetic agents are used in ophthalmic practice – prostaglandin analogues, beta-blockers, alpha agonists and carbonic anhydrase inhibitors, or combination of these drugs. These can get systemically absorbed and produce respective interactions and side effects.

Perioperative visual disturbances may be due to increased intraocular pressure, ischemic optic neuropathy, retinal vessel occlusion, some of them may be catastrophic with visual loss. Complications giving rise to visual disturbances or loss can be prevented if precautions are taken in the pre-operative and intraoperative period. At risk patient conditions include diabetes, hypertension, pre-existing glaucoma, smoking, and hypercoagulability.

If eyes are not protected during general anaesthesia, corneal ulceration can lead to blindness.

At risk patient position include, steep head down/Trendelenburg, and prone position. Patients undergoing laparoscopic gynecological and colorectal surgery in a prolonged head-down position are likely to experience raised IOP. This makes them vulnerable to the high risk of post-operative vision loss. It must be borne in mind that prolonged pneumoperitoneum with steep head down tilt is a bad combination. It is more than likely to affect cerebral circulation and the ocular pressures. A head up tilt may also pose problems if given for over two hours, especially in patients who are hypovolemic or hypotensive due to any cause.

Studies have reported a mean increase of 13 mm Hg of intraocular pressure as compared to preoperative levels, in patients undergoing prolonged laparoscopy assisted gynaecological surgery as well as robotic assisted urological surgery. It is also proven that visual impairment related to patient positioning and laparoscopic surgery is ‘time dependent’.

Prevention of increase in IOP greater than 40mmHg (critical threshold pressure) is important in any procedure, requiring steep head down tilt. Hence, a short break of 5-7 minutes, every two hours is advised in prolonged procedures.

Patients in prone position during major surgical procedures are at great danger of visual impairment. We need to be aware of this under-recognized but potentially catastrophic complication. Ten degrees of reverse Trendelenburg attenuate the rise in IOP during prone spine surgery.

This case highlights rare but catastrophic complication that is usually preventable.

The key is to identify at-risk group of patients, positioning required for the surgery and potential duration of surgery. Planning with the surgical team, the ‘timing’ and the ‘breaks’ from positioning is vital to prevent ophthalmic complications.

References

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