Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 465-466

Surgical emphysema and pneumothorax following open cholecystectomy under general anesthesia


Department of Anaesthesia, Pain and Critical Care, ESIC Medical College PGIMSR, Rajajinagar, Bangalore, Karnataka, India

Date of Submission25-Oct-2013
Date of Acceptance22-Aug-2014
Date of Web Publication27-Aug-2014

Correspondence Address:
Prasad G Curpod
No 131, 4th Main Road, Ganganagar, Bangalore 560 032, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.139598

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  Abstract 

We present a case of surgical emphysema and bilateral pneumothorax following open cholecystectomy under general anesthesia in a patient previously treated for lower respiratory infection. Pneumothorax following open cholecystectomy under general anesthesia is rare. The incidence is about 0.01-0.4%. Immediate recognition and prompt treatment is essential. A female patient with history of treated lower respiratory tract infection 6 weeks before surgery posted for open cholecystectomy. Induction/maintenance phase was uneventful. At the time of extubation, surgical emphysema was noticed in the chest, neck, and face. Airway pressures and vitals were normal. Chest radiograph confirmed pneumothorax, which was promptly treated. Pneumothorax following general anesthesia is due to injury to the pleura or rupture of intrapulmonary alveoli. The probable precipitating cause in our patient could be because of previous history of lower respiratory tract infection, intermittent positive-pressure ventilation, and nitrous oxide. High index of suspicion is required to diagnose pneumothorax in a patient with surgical emphysema with stable vital data and normal airway pressures.

Keywords: lower respiratory tract infection, open cholecystectomy, pneumothorax, surgical emphysema


How to cite this article:
Curpod PG, Suresh G, Giri TV, Azha SG. Surgical emphysema and pneumothorax following open cholecystectomy under general anesthesia. Ain-Shams J Anaesthesiol 2014;7:465-6

How to cite this URL:
Curpod PG, Suresh G, Giri TV, Azha SG. Surgical emphysema and pneumothorax following open cholecystectomy under general anesthesia. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2019 Sep 21];7:465-6. Available from: http://www.asja.eg.net/text.asp?2014/7/3/465/139598


  Introduction Top


Pneumothorax with surgical emphysema following open cholecystectomy under general anesthesia is rare. The incidence is about 0.01-0.4% [1]. It is important to be aware of this rare but life-threatening complication. It is difficult to diagnose and find the cause of pneumothorax during general anesthesia. Failure to recognize and provide prompt treatment may result in fatality. Treatment can vary from simple close observation in a stable patient to immediate chest tube thoracostomy in unstable patient.


  Case report Top


A female patient aged 55 years, weighing 70 kg posted for open cholecystectomy. Medical history suggested that she had lower respiratory tract infection 6 weeks before, for which she had taken prompt treatment. At present, she was asymptomatic. General physical systemic examination and investigations were within normal limits. Patient was accepted with ASA II risk under general anesthesia.

On the day of surgery, after the complete checklist, patient was connected to ECG, SpO 2 , and non invasive blood pressure (NIBP) monitors. After initial recording, patient was preoxygenated for 3 min and anesthesia was induced with injection of midazolam (1 mg), fentanyl (100 μg), thiopentone (250 mg), and vecuronium bromide (7 mg). Patient's trachea was intubated with portex 7.5 mm endotracheal tube. Bilateral air entry was confirmed, fixed at 20 cm at angle of the mouth, and continuous ETCO 2 and airway pressures were monitored. Patient was maintained with oxygen 3 l, nitrous oxide 3 l, and sevoflurane 1-1.5% and intermittent positive-pressure ventilation (IPPV) with closed circuit. The course of the surgery was uneventful. At the time of reversal, surgical emphysema was noticed in the chest, neck, and face; airway pressures and vitals were within normal limits. On examination, air entry was decreased on the left side. Portable chest radiograph showed left-sided pneumothorax with collapse of the lung and soft tissue emphysema in the chest and neck [Figure 1].
Figure 1: Portable chest radiograph revealed left-sided pneumothorax with collapse of the lung and soft tissue emphysema in the chest and neck.

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Intercostal drainage with underwater seal was placed in the fifth intercostal space in axilla on the left side, and air entry was improved on the left side. Water column in the intercostal drain was moving well with respiration. A repeat chest radiograph revealed full expansion of the lungs with intercostal drain in the left hemithorax with expansion of the lung [Figure 2].
Figure 2: A repeat chest radiograph revealed full expansion of the lungs with intercostal drain in the left hemithorax with expansion of the lung.

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Patient was shifted to ICU with endotracheal tube and IPPV for observations and extubated after 24 h. Surgical emphysema disappeared in next 48 h. intercoastal drain (ICD) was removed on the fifth postoperative day. At 1-month follow-up, computed tomography scan of the chest was performed. It revealed bronchiectasis changes.


  Discussion Top


Pneumothorax with surgical emphysema following general anesthesia is relatively common with laparoscopic cholecystectomy [1,2]. However, pneumothorax following open cholecystectomy is rare [3]. Pneumothorax can occur because of intrapulmonary alveoli rupture, injury to the visceral and parietal pleura, which may be due to disease per se (bronchiectasis, emphysematous bullae), malfunctioning of the valve, IPPV, nitrous oxide, and surgical causes [4-6]. Pneumothorax during anesthesia is commonly due to overdistension of the lungs by positive-pressure ventilation, and concomitant use of nitrous oxide precipitates the problem. Air from ruptured alveoli may dissect along perivascular and peribronchial sheaths into the pleural cavity and mediastinum. More pressure propels air to the cervical fascia and results in subcutaneous emphysema in the chest, neck, and face. Pneumothorax can also be caused by surgical trauma of the peritoneum and pleurae; malfunctioning of the adjustable pressure limiting (APL) valve results in development of intrinsic positive end expiratory pressure (PEEP), which precipitates pneumothorax. General anesthesia and IPPV in a patient with respiratory infections are prone for pneumothorax. The probable precipitating cause in our patient is because of previous history of lower respiratory tract infection (bronchiectasis), IPPV, and nitrous oxide.


  Conclusion Top


Patients with treated lower respiratory tract infection are prone for complications because of undiagnosed occult bronchiectasis. High index of suspicion is required to diagnose pneumothorax in a patient with surgical emphysema with stable vitals and normal airway pressures.





 
  References Top

1.Kumar G, Singh AK. Pneumothorax during laparoscopic cholecystectomy. MJAFI 2007; 63:277-278.  Back to cited text no. 1
    
2. Kaushik R, Attri AK. Spontaneous pneumothorax - a rare complication of laparoscopic cholecystectomy. Indian JSurg 2004; 66:294-296.  Back to cited text no. 2
    
3. Zahoor SA, Khairat M, Bashir D, Nissa WU. Tension pneumothorax following open cholecystectomy under general anaesthesia. JK Science 2007;9:37-38.  Back to cited text no. 3
    
4. Sandra L. Supraclavicular & infraclavicular block: pneumothorax. JL Atlee. Complications in anaesthesia. 2nd ed. Philadelphia: Saunders Elsevier; 2007. 251-253.  Back to cited text no. 4
    
5. Patkar GA, Jagtap SR. Bilateral tension pneumothorax and massive surgical emphysema during anaesthesia. Ind J Anaesth 2004; 48:221-223.  Back to cited text no. 5
    
6. Kaur S, Cortellia J, Vacanti CA. Diffusion of nitrous oxide into pleural cavity. Br J Anaesth 2001; 87:894-896.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]


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