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Pneumothorax During Anesthesia

A 54-year-old man under GA, was found abnormal diaphragm movement during operation

Presentation: Ri / Supervisor: CR VS Nov. 29, 2005

Brief History
‡ 54 year-old man ‡ HBV carrier diagnosed by health check-up ‡ Sonogram in hospital: - a small liver tumor(about 1*1 cm) ‡ Abdominal CT in hospital: - one tumor (1.6cm) at S#5-8 junctional area - and another tumor (1.2cm) at S#6 of liver p suspected HCC

Past History ‡ DM(-) HTN(-) ‡ Alcohol consumption: social ‡ Smoking: 1PPD for 40years and quit for 2 months ‡ Allergy: NKA ‡ Op history:Nil ‡ Occupation: guard .

JVE (-) ‡ Chest: symmetric expansion.8/76/18 ‡ HEENT: Conjunctiva:pale. murmur(-) . T/P/R: 36. clear breathing sound ‡ Heart: RHB.Physical Examination ‡ Vital signs: BP:122/78 mmHg. LAP (-). Sclera:anicteric ‡ Neck: supple.

rebound tenderness (-).Physical Examination ‡ Abdomen: soft and flat.: edema(-). petechiae(-). clubbing finger(-). cyanosis(-) . tremor(-). tenderness (-). Bowel sound: normoactive ‡ Back: CV angle knocking pain (-) ‡ Ext. Liver/Spleen: impalpable. purpura(-). shifting dullness (-).

Pre-OP assessment ‡ A 54-year-old male ‡ HBV carrier ‡ Smoking: 1PPD for 40years and quit for 2 months ‡ ASA class: II ‡ Pre-OP CXR: .

Check bleeding and close the wound in layers . echo for finding hepatic tumors 6. Subcostal incision at right side. supine position 2. Mobilization the liver.Operation: Segmental Hepatectomy 1. Segmental hepatectomy at S6 and S7 7. ETGA. Dissect abdominal wall in layers 4. Perform cholecystectomy 5. with xyphoid extension 3.

Intra-operation(3) Abnormal diaphragm movement was found .

Pain relief. CXR showed pneumothorax ± 16:40.CXR for ± 15:40.Demeral 20mg IV stat for pain ± 15:50.Post-operation Condition(3) ‡ 11/14 ± 15:20.Keep SpO2 monitor .Observation and keep O2 use .Demeral 40mg IV stat for pain ± 15:30.

Post-operation Condition(4) ‡ 11/16: ± Mild decreased breathing sound over right side ± Chest wall pain and sorethroat ± No desaturation. mild dyspnea .

Post-operation ‡ Impression: Iatrogenic pneumothorax ‡ Plan: Observation and supportive care ‡ Discharged on 11/22 under stable condition .

Discussion Complication of CVC  Iatrogenic pneumothorax  Iatrogenic pneumothorax in anesthetized patient during operation  Tension pneumothorax in anesthetized patient during operation  Prevention  .

Diagnosis of Pneumothorax During Operation ‡ ‡ ‡ ‡ ‡ General principles Precipitating factors Signs Chest-X-ray Needle test .

14: e18 .General Principles ‡ One of exclusion ‡ Clinical observation: not reliable Unilaterally decreased breathing sounds: ‡ Think of the possibility whenever the endotrachial intubation is most common presence of deviation: situations high risk Tracheal more likely due to slight rotation of head on the neck Qual Saf Health Care 2005.

crush injury ‡ Blunt trauma/deceleration injury ‡ Problem with pleural drain already sited ‡ Airway overpressure.Precipitating Factors ‡ Any needle or instrumentation. 14: e18 . obstructed ETT ‡ Emphysema or bullous lung disease Qual Saf Health Care 2005. even days previously ‡ External cardiac massage ‡ Fractured ribs.

raised CVP Tracheal deviation Qual Saf Health Care 2005. 14: e18 .Signs ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Increased PIP and decreased pulmonary compliance Difficulty with ventilation/respiratory distress Desaturation Hypotension Tachycardia Unilateral chest expansion Abdominal distension Distended neck veins.

14: e18 .Urgent CXR ‡ If there is any suspicion ‡ May not detect a non-tension pneumothorax in a supine patient ‡ Inspiratory AP and lateral views are preferable ‡ In our case« Qual Saf Health Care 2005.

midclavicular line .Needle Test ‡ Needle aspiration of the pleural space or insert a short intravenous cannula 10 test negative in deteriorating patient: ‡ Needle or 20ml syringe containing 3ml of water or saline and 23G needle Loculated tension pneumothorax Insert in: .2nd tamponade Cardiacintercostal space. midaxillary line p Small stream of bubbles: negative p Large bubbles: positive Qual Saf Health Care 2005. 14: e18 .4th intercostal space.

Management of Pneumothorax During Operation Respiratory 2004. 9: 157-164 .

Management of Pneumothorax During Operation ‡ Continuously observe the bottle for bubbling and/or swinging ‡ Be vigilant for further deterioration in the patient Increased or continuing air leak Kinked/blocked/capped/clamped underwater seal drain Contralateral pneumothorax Misplaced pleural drain tip Trauma caused by drain insertion Misconnection of drain apparatus Qual Saf Health Care 2005. 14: e18 .

pericardiocentesis .Management of Pneumothorax During Operation ‡ If the problem persists«.opening the chest Qual Saf Health Care 2005. Consider cardiac tamponade . 14: e18 .

Tension Pneumothorax ‡ In ventilated patients: .67.122:678±83 ) Emerg Med J 2005.17-23) .more serious in ventilated patients reaching 91% mortality rates in one series (Chest 2002. 22:8-16 .From simple pneumothorax when diagnosis is delayed .mortality rate in one previous study: 31% (Thorac Cardiovasc Surg 1974.

22:8-16 . simple pneumothorax Emerg Med J 2005.Tension Pneumothorax ‡ The most common etiologies are either iatrogenic or related to trauma Trauma (blunt or penetrating) Barotrauma due to positive-pressure ventilation Central venous catheter placement Conversion of idiop athic. spontaneous.

raised CVP Tracheal deviation Murray and Nadel's Textbook of Respiratory Medicine. 4th edition .Diagnosis of Tension Pneumothorax ‡ Usually herald by a sudden deterioration in the cardiopulmonary status of the patient Volume type ventilation ‡ Symptoms andincrease markedly ± peak pressure signs Difficulty with ventilation / respiratory distress Pressure-support ventilation ‡ Clinical situation and the physical findings Desaturation decrease markedly ± tidal volume Hypotension usually stronglycatheters the diagnosis With Swan-Ganz suggest Do not waste time trying to establish the diagnosis of Heart rate changes ± increased pulmonary artery pressures tension pneumothorax radiologically Unilateral chest expansion or cardiac index ± decreased cardiac output Abdominal distension Distended neck veins.

Treatment of Tension Pneumothorax ‡ High concentration of oxygen to alleviate hypoxia (Turn off N2O. FiO2 to 100%) ‡ Support the circulation ‡ Large-bore (14~16-gauge) IV catheter ‡ Tube thoracostomy Insert in: . 4th edition .4th intercostal space.2nd intercostal space. midaxillary line pneumothoraces Diagnositic but may not completely relieve TPT Murray and Nadel's Textbook of Respiratory Medicine. midclavicular ‡ Consider the possibility of bilateral line .

1995 Sep.Delayed Pneumothorax Am J Emerg Med.13(5):532-5 .

process. 14: e18 .Scan: as and Eliminate machine Endotracheal tubeneeded. and responses Qual Saf Health Care 2005.monitors and Review equipment ReviewCheck: whenever you are worried AirwayAlert/ready laryngeal mask) . ABCD patient) and emergency ‡ COVERcheck.Emergency Circulation (in more detail than above) Drugs (consider all given or not given) A Be Aware of Air and Allergy SWIFT CHECK of patient. or every 5 minutes . surgeon. alert/ready.(with face or Breathing (with spontaneous ventilation) . Vaporisers Ventilation (intubated .A SWIFT CHECK . Capnograph. and Color (saturation) ‡ SCARE Oxygen supply and Oxygen analyser Scan.Structural Thinking Circulation.