pneumothorax during anesthesia presentation: ri 周浩昌 / 林明恩 supervisor: cr 黃信豪 vs...

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