pneumothorax during anesthesia
DESCRIPTION
A 54-year-old man under GA, was found abnormal diaphragm movement during operation. Pneumothorax During Anesthesia. 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 - PowerPoint PPT PresentationTRANSCRIPT
Pneumothorax During Anesthesia
Pneumothorax During Anesthesia
Presentation: Ri 周浩昌 / 林明恩Supervisor: CR 黃信豪 VS 詹光政 Nov. 29, 2005
Presentation: Ri 周浩昌 / 林明恩Supervisor: CR 黃信豪 VS 詹光政 Nov. 29, 2005
A 54-year-old man under GA, was found abnormal diaphragm movement during operation
Brief HistoryBrief History
54 year-old manHBV carrier diagnosed by health check-upSonogram in 三重 hospital:
- a small liver tumor(about 1*1 cm)Abdominal CT in 亞東 hospital:
- one tumor (1.6cm) at S#5-8 junctional area
- and another tumor (1.2cm) at S#6 of liver
suspected HCC
54 year-old manHBV carrier diagnosed by health check-upSonogram in 三重 hospital:
- a small liver tumor(about 1*1 cm)Abdominal CT in 亞東 hospital:
- one tumor (1.6cm) at S#5-8 junctional area
- and another tumor (1.2cm) at S#6 of liver
suspected HCC
Past HistoryPast History
DM(-) HTN(-)Alcohol consumption: socialSmoking: 1PPD for 40years and quit for 2
monthsAllergy: NKAOp history:NilOccupation: guard
DM(-) HTN(-)Alcohol consumption: socialSmoking: 1PPD for 40years and quit for 2
monthsAllergy: NKAOp history:NilOccupation: guard
Physical ExaminationPhysical Examination
Vital signs:
BP:122/78 mmHg, T/P/R: 36.8/76/18HEENT: Conjunctiva:pale, Sclera:anictericNeck: supple, LAP (-), JVE (-)Chest: symmetric expansion, clear
breathing soundHeart: RHB, murmur(-)
Vital signs:
BP:122/78 mmHg, T/P/R: 36.8/76/18HEENT: Conjunctiva:pale, Sclera:anictericNeck: supple, LAP (-), JVE (-)Chest: symmetric expansion, clear
breathing soundHeart: RHB, murmur(-)
Physical ExaminationPhysical Examination
Abdomen: soft and flat, tenderness (-), rebound tenderness (-), shifting dullness (-), Liver/Spleen: impalpable; Bowel sound: normoactive
Back: CV angle knocking pain (-)Ext.: edema(-), clubbing finger(-), tremor(-),
petechiae(-), purpura(-), cyanosis(-)
Abdomen: soft and flat, tenderness (-), rebound tenderness (-), shifting dullness (-), Liver/Spleen: impalpable; Bowel sound: normoactive
Back: CV angle knocking pain (-)Ext.: edema(-), clubbing finger(-), tremor(-),
petechiae(-), purpura(-), cyanosis(-)
Pre-OP assessmentPre-OP assessment
A 54-year-old maleHBV carrierSmoking: 1PPD for 40years and quit for
2 monthsASA class: IIPre-OP CXR:
A 54-year-old maleHBV carrierSmoking: 1PPD for 40years and quit for
2 monthsASA class: IIPre-OP CXR:
Operation: Segmental HepatectomyOperation: Segmental Hepatectomy
1. ETGA, supine position2. Subcostal incision at right side, with
xyphoid extension3. Dissect abdominal wall in layers4. Perform cholecystectomy
5. Mobilization the liver, echo for finding hepatic tumors
6. Segmental hepatectomy at S6 and S77. Check bleeding and close the wound in layers
1. ETGA, supine position2. Subcostal incision at right side, with
xyphoid extension3. Dissect abdominal wall in layers4. Perform cholecystectomy
5. Mobilization the liver, echo for finding hepatic tumors
6. Segmental hepatectomy at S6 and S77. Check bleeding and close the wound in layers
Intra-operation(3)Intra-operation(3)
Abnormal diaphragm movement was found
Post-operation Condition(3)
Post-operation Condition(3)
11/14 15:20- Demeral 40mg IV stat
for pain 15:30- CXR for 右胸微凸 15:40- Demeral 20mg IV stat
for pain 15:50- Pain relief, CXR
showed pneumothorax 16:40- Observation and keep
O2 use
- Keep SpO2 monitor
11/14 15:20- Demeral 40mg IV stat
for pain 15:30- CXR for 右胸微凸 15:40- Demeral 20mg IV stat
for pain 15:50- Pain relief, CXR
showed pneumothorax 16:40- Observation and keep
O2 use
- Keep SpO2 monitor
Post-operation Condition(4)
Post-operation Condition(4)
11/16:Mild decreased
breathing sound over right side
Chest wall pain and sorethroat
No desaturation, mild dyspnea
11/16:Mild decreased
breathing sound over right side
Chest wall pain and sorethroat
No desaturation, mild dyspnea
Post-operationPost-operation
Impression: Iatrogenic pneumothoraxPlan: Observation and supportive careDischarged on 11/22 under stable
condition
Impression: Iatrogenic pneumothoraxPlan: Observation and supportive careDischarged on 11/22 under stable
condition
DiscussionDiscussion
Complication of CVCIatrogenic pneumothoraxIatrogenic pneumothorax in anesthetized
patient during operationTension pneumothorax in anesthetized
patient during operationPrevention
Complication of CVCIatrogenic pneumothoraxIatrogenic pneumothorax in anesthetized
patient during operationTension pneumothorax in anesthetized
patient during operationPrevention
Diagnosis of Pneumothorax During OperationDiagnosis of Pneumothorax During Operation
General principlesPrecipitating factorsSignsChest-X-rayNeedle test
General principlesPrecipitating factorsSignsChest-X-rayNeedle test
General PrinciplesGeneral Principles
One of exclusionClinical observation: not reliableThink of the possibility whenever the
presence of high risk situations
One of exclusionClinical observation: not reliableThink of the possibility whenever the
presence of high risk situations
Qual Saf Health Care 2005; 14: e18
Unilaterally decreased breathing sounds: endotrachial intubation is most common
Tracheal deviation: more likely due to slight rotation of head on the neck
Precipitating FactorsPrecipitating Factors
Any needle or instrumentation, even days previously
External cardiac massageFractured ribs, crush injuryBlunt trauma/deceleration injuryProblem with pleural drain already sitedAirway overpressure, obstructed ETTEmphysema or bullous lung disease
Any needle or instrumentation, even days previously
External cardiac massageFractured ribs, crush injuryBlunt trauma/deceleration injuryProblem with pleural drain already sitedAirway overpressure, obstructed ETTEmphysema or bullous lung disease
Qual Saf Health Care 2005; 14: e18
SignsSigns
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
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: e18
Urgent CXRUrgent CXR
If there is any suspicionMay not detect a non-tension pneumothorax in
a supine patientInspiratory AP and lateral views are preferableIn our case…
If there is any suspicionMay not detect a non-tension pneumothorax in
a supine patientInspiratory AP and lateral views are preferableIn our case…
Qual Saf Health Care 2005; 14: e18
Needle TestNeedle Test
Needle aspiration of the pleural space or insert a short intravenous cannula
Needle test negative in deteriorating patient:
Loculated tension pneumothorax
Cardiac tamponade
Needle aspiration of the pleural space or insert a short intravenous cannula
Needle test negative in deteriorating patient:
Loculated tension pneumothorax
Cardiac tamponade
Qual Saf Health Care 2005; 14: e18
10 or 20ml syringe containing 3ml of water or saline and 23G needle
Insert in: - 2nd intercostal space, midclavicular line - 4th intercostal space, midaxillary line Small stream of bubbles: negative Large bubbles: positive
Management of Pneumothorax During OperationManagement of Pneumothorax During Operation
Respiratory 2004; 9: 157-164
Management of Pneumothorax During OperationManagement of Pneumothorax During Operation
Continuously observe the bottle for bubbling and/or swinging
Be vigilant for further deterioration in the patient
Continuously observe the bottle for bubbling and/or swinging
Be vigilant for further deterioration in the patient
Qual Saf Health Care 2005; 14: e18
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
Management of Pneumothorax During OperationManagement of Pneumothorax During Operation
If the problem persists…. If the problem persists….
Qual Saf Health Care 2005; 14: e18
Consider cardiac tamponade - pericardiocentesis - opening the chest
Tension PneumothoraxTension Pneumothorax
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 )
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
The most common etiologies are either
iatrogenic or related to trauma
The most common etiologies are either
iatrogenic or related to trauma
Tension PneumothoraxTension Pneumothorax
Emerg Med J 2005; 22:8-16
Trauma (blunt or penetrating) Barotrauma due to positive-pressure ventilation Central venous catheter placement Conversion of idiop athic, spontaneous, simple
pneumothorax
Diagnosis of Tension PneumothoraxDiagnosis of Tension Pneumothorax
Usually herald by a sudden deterioration in the cardiopulmonary status of the patient
Symptoms and signsClinical situation and the physical findings
usually strongly suggest the diagnosis
Usually herald by a sudden deterioration in the cardiopulmonary status of the patient
Symptoms and signsClinical situation and the physical findings
usually strongly suggest the diagnosis
Difficulty with ventilation / respiratory distressDesaturationHypotensionHeart rate changesUnilateral chest expansionAbdominal distensionDistended neck veins, raised CVPTracheal deviation
Volume type ventilation – peak pressure increase markedly
Pressure-support ventilation – tidal volume decrease markedly
With Swan-Ganz catheters – increased pulmonary artery pressures – decreased cardiac output or cardiac index
Do not waste time trying to establish the diagnosis of tension pneumothorax radiologically
Murray and Nadel's Textbook of Respiratory Medicine, 4th edition
Treatment of Tension PneumothoraxTreatment of Tension Pneumothorax
High concentration of oxygen to alleviate hypoxia (Turn off N2O, FiO2 to 100%)
Support the circulationLarge-bore (14~16-gauge) IV catheter Tube thoracostomy Consider the possibility of bilateral
pneumothoraces
High concentration of oxygen to alleviate hypoxia (Turn off N2O, FiO2 to 100%)
Support the circulationLarge-bore (14~16-gauge) IV catheter Tube thoracostomy Consider the possibility of bilateral
pneumothoraces
Insert in: - 2nd intercostal space, midclavicular line - 4th intercostal space, midaxillary line
Diagnositic but may not completely relieve TPT
Murray and Nadel's Textbook of Respiratory Medicine, 4th edition
Delayed PneumothoraxDelayed Pneumothorax
Am J Emerg Med. 1995 Sep;13(5):532-5
SCARE COVER ABCD - A SWIFT CHECK
SCARE COVER ABCD - A SWIFT CHECK
Qual Saf Health Care 2005; 14: e18
Structural ThinkingStructural Thinking
Scan, check, alert/ready, emergency - Scan: as needed, or every 5 minutes - Check: whenever you are worried - Alert/ready - Emergency
Circulation, Capnograph, and Color (saturation) Oxygen supply and Oxygen analyser Ventilation (intubated patient) and Vaporisers Endotracheal tube and Eliminate machine Review monitors and Review equipment Airway (with face or laryngeal mask) Breathing (with spontaneous ventilation) 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