Pneumothorax During Anesthesia A 54 yearold man under

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Pneumothorax During Anesthesia A 54 -year-old man under GA, was found abnormal diaphragm movement

Pneumothorax During Anesthesia A 54 -year-old man under GA, was found abnormal diaphragm movement during operation Presentation: Ri 周浩昌/林明恩 Supervisor: CR 黃信豪 VS 詹光政 Nov. 29, 2005

Brief History 54 year-old man l HBV carrier diagnosed by health check-up l Sonogram

Brief History 54 year-old man l HBV carrier diagnosed by health check-up l Sonogram in 三重 hospital: - a small liver tumor(about 1*1 cm) l Abdominal CT in 亞東 hospital: - one tumor (1. 6 cm) at S#5 -8 junctional area - and another tumor (1. 2 cm) at S#6 of liver suspected HCC l

Past History DM(-) HTN(-) l Alcohol consumption: social l Smoking: 1 PPD for 40

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

Physical Examination Vital signs: BP: 122/78 mm. Hg, T/P/R: 36. 8/76/18 l HEENT: Conjunctiva:

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

Physical Examination Abdomen: soft and flat, tenderness (-), rebound tenderness (-), shifting dullness (-),

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

Pre-OP assessment A 54 -year-old male l HBV carrier l Smoking: 1 PPD for

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

Operation: Segmental Hepatectomy 1. ETGA, supine position 2. Subcostal incision at right side, with

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

Intra-operation(3) Abnormal diaphragm movement was found

Intra-operation(3) Abnormal diaphragm movement was found

Post-operation Condition(3) l 11/14 l 15: 20 - Demeral 40 mg IV stat for

Post-operation Condition(3) l 11/14 l 15: 20 - Demeral 40 mg IV stat for pain l 15: 30 - CXR for 右胸微凸 l 15: 40 - Demeral 20 mg IV stat for pain l 15: 50 - Pain relief, CXR showed pneumothorax l 16: 40 - Observation and keep O 2 use - Keep Sp. O 2 monitor

Post-operation Condition(4) l 11/16: l Mild decreased breathing sound over right side l Chest

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

Post-operation Impression: Iatrogenic pneumothorax l Plan: Observation and supportive care l Discharged on 11/22

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

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

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

Diagnosis of Pneumothorax During Operation l General principles l Precipitating factors l Signs l

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

General Principles One of exclusion l Clinical observation: not reliable decreased breathing sounds: l

General Principles One of exclusion l Clinical observation: not reliable decreased breathing sounds: l Think. Unilaterally of the possibility whenever the endotrachial intubation is most common presence of high risk situations Tracheal deviation: l more likely due to slight rotation of head on the neck Qual Saf Health Care 2005; 14: e 18

Precipitating Factors Any needle or instrumentation, even days previously l External cardiac massage l

Precipitating Factors Any needle or instrumentation, even days previously l External cardiac massage l Fractured ribs, crush injury l Blunt trauma/deceleration injury l Problem with pleural drain already sited l Airway overpressure, obstructed ETT l Emphysema or bullous lung disease l Qual Saf Health Care 2005; 14: e 18

Signs l l l l l Increased PIP and decreased pulmonary compliance Difficulty with

Signs l l l l l Increased PIP and decreased pulmonary compliance Difficulty with ventilation/respiratory distress Desaturation Hypotension Tachycardia Unilateral chest expansion Abdominal distension Distended neck veins, raised CVP Tracheal deviation Qual Saf Health Care 2005; 14: e 18

Urgent CXR If there is any suspicion l May not detect a non-tension pneumothorax

Urgent CXR If there is any suspicion l May not detect a non-tension pneumothorax in a supine patient l Inspiratory AP and lateral views are preferable l In our case… l Qual Saf Health Care 2005; 14: e 18

Needle Test Needle aspiration of the pleural space or insert a short intravenous cannula

Needle Test Needle aspiration of the pleural space or insert a short intravenous cannula 10 or 20 ml syringe containing 3 ml of waterpatient: or l Needle test negative in deteriorating saline and 23 G needle l Loculated Insert in: tension pneumothorax - 2 nd intercostal space, midclavicular line l Cardiac tamponade l - 4 th intercostal space, midaxillary line Small stream of bubbles: negative Large bubbles: positive Qual Saf Health Care 2005; 14: e 18

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

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

Management of Pneumothorax During Operation Continuously observe the bottle for bubbling and/or swinging l

Management of Pneumothorax During Operation Continuously observe the bottle for bubbling and/or swinging l Be vigilant for further deterioration in the patient l 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: e 18

Management of Pneumothorax During Operation l If the problem persists…. Consider cardiac tamponade -

Management of Pneumothorax During Operation l If the problem persists…. Consider cardiac tamponade - pericardiocentesis - opening the chest Qual Saf Health Care 2005; 14: e 18

Tension Pneumothorax l In ventilated patients: - From simple pneumothorax when diagnosis is delayed

Tension Pneumothorax l In ventilated patients: - From simple pneumothorax when diagnosis is delayed - mortality rate in one previous study: 31% (Thorac Cardiovasc Surg 1974; 67, 17 -23) - more serious in ventilated patients reaching 91% mortality rates in one series (Chest 2002; 122: 678– 83 ) Emerg Med J 2005; 22: 8 -16

Tension Pneumothorax l The most common etiologies are either iatrogenic or related to trauma

Tension Pneumothorax l 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, simple pneumothorax Emerg Med J 2005; 22: 8 -16

Diagnosis of Tension Pneumothorax Usually herald by a sudden deterioration in the cardiopulmonary status

Diagnosis of Tension Pneumothorax Usually herald by a sudden deterioration in the cardiopulmonary status of the patient Volume typeand ventilation l Symptoms signs – peak pressure increase markedly Difficulty with ventilation respiratory distress l Clinical situation and /the physical findings Pressure-support ventilation Desaturation – tidal volume decrease markedly usually strongly suggest the diagnosis Hypotension l With Swan-Ganz catheters Do notrate waste time trying to establish the diagnosis of Heart changes – increased pulmonary artery pressures tension pneumothorax radiologically Unilateral chest expansion – decreased cardiac output or cardiac index Abdominal distension Distended neck veins, raised CVP Tracheal deviation Murray and Nadel's Textbook of Respiratory Medicine, 4 th edition

Treatment of Tension Pneumothorax High concentration of oxygen to alleviate hypoxia (Turn off N

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

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

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

Structural Thinking l SCARECapnograph, and Color (saturation) Circulation, Oxygen supply. ABCD and Oxygen analyser.

Structural Thinking l SCARECapnograph, and Color (saturation) Circulation, Oxygen supply. ABCD and Oxygen analyser. CHECK l COVER - A SWIFT Scan, check, alert/ready, emergency Ventilation (intubated patient) and Vaporisers - Scan: asand needed, or every 5 minutes Endotracheal tube Eliminate machine Check: and whenever you are worried Review -monitors Review equipment Airway -(with face or laryngeal mask) Alert/ready Breathing (with spontaneous ventilation) - 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, surgeon, process, and responses Qual Saf Health Care 2005; 14: e 18