Post-Operative Chapters 23-25

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

POST-OPERATIVE – Chapter 23

Subcutaneous Emphysema following Maxillo-facial Surgery

A 37-year-old woman was posted for a Maxillo-facial surgery (mandible and maxillary osteotomy) under general anaesthesia. She was clinically normal, and investigations were also normal. Routine general anaesthesia was administered with a naso-tracheal intubation, and, the whole course of surgery which lasted for about three hours was smooth. She recovered well and was extubated.

Post operatively, after about half an hour, she started developing a swelling that originated at the neck and began spreading rapidly to her face, and trunk. The patient complained of difficulty in breathing. On palpation, crepitus was felt over her chest and neck. It was diagnosed as subcutaneous emphysema.

Multiple skin incisions were made to release air. She had no further increase in the swelling, and her general condition improved in 2-3 hours. The source for subcutaneous emphysema could not be identified. Chest x-ray confirmed subcutaneous emphysema, with no evidence of pneumomediastinum or pneumothorax. Fibre optic scope of respiratory tract did not identify anything abnormal. She was asymptomatic and hence discharged on day three.

She returned a week later to the outpatient clinic with a small swelling over her neck and some difficulty in breathing while lying flat. A diagnostic fibre optic bronchoscopy was repeated. This time a rent in the trachea just beyond the vocal cords was identified. In order to protect the airway and allow for healing process, a low tracheostomy was done.

Patient was reviewed after 2 weeks. A repeat bronchoscopy performed at this juncture showed that the rent had healed well and tracheostomy was closed. Patient recovered with no further problems.

I would like to recall a patient who was shifted to the post-operative ward, with the tube following release of TMJ ankylosis. Oxygenation using a T piece was advised. The floor nurse fitted the oxygen line into the tube without allowing any space for expired gases to escape, and the patient developed pneumothorax, for which an ICD had to be done!

Discussion

Here we had an unusual case of subcutaneous emphysema (which can be life threatening) due to a small rent in the tracheal wall in the immediate postoperative period. This is not a common perioperative event; however, one must bear this in mind during head and neck surgeries, involving structures close to respiratory tract. Diagnosis at the right time and appropriate management saves the patient.

Possible causes of subcutaneous emphysema;

Patient factors: Congenital tracheal anomalies, weakness of the membranous trachea, chronic use of steroids and chronic obstructive pulmonary disease
Iatrogenic factors: Traumatic intubation, multiple attempts at intubation, use of stylet, re- positioning of the ET tube without deflating the cuff can cause trauma to the soft tissues of the pharynx, hypopharynx and trachea. Patient movement or coughing during intubation, and patient head and neck movement after intubation intraoperatively as in head and neck surgery may potentiate mucosal wall damage.

Long procedure with nitrous oxide on flow may increase the cuff pressure, (it is advisable not to over inflate the cuff.)

Severe retching in postoperative period, causing an increase in alveolar pressure leading to alveolar rupture and air tracking up to mediastinum and subcutaneous plane can occur.

Our patient had none of predisposing factors. Intubation was straightforward and no trauma was caused. Intraoperative head and neck movements, possible raised cuff pressure could be implicated in tracheal wall damage. No nausea and vomiting were observed in the immediate postoperative period.
Immediate management with release of air is essential if the condition is life threatening. Symptoms such as difficulty in breathing, chest pain, and hemodynamic compromise warrant immediate action. If patient is asymptomatic, subcutaneous emphysema is usually self-resolving within 48 hours, provided the point of air leak is small and self-healing.
Subcutaneous emphysema following tonsillectomy has been reported as a rare complication in literature. Deep dissection into the tonsil fossa may cause a breach of the superior constrictor muscle and the underlying fascia. Airway pressure must be monitored in the intra-operative period to prevent such post-operative complications.

References

Wylie Churchill-Davidson’s A Practice of Anesthesia 7th Edition Page 843. Edited by Thomas EJ Healy, Paul R Knight
Peterson’s Principles of Oral and Maxillofacial Surgery, Volume 1By Michael Miloro, G.E. Ghali, Peter Larsen, Pg 1263
Atlas of Oral and Maxillofacial Surgery Pg 1014 By Deepak Kademani, Paul Tiwana
E. O’Neill, J. P. Giffin, and J. E. Cottrell, “Pharyngeal and esophageal perforation following endotracheal intubation,” Anesthesiology, vol. 60, no. 5, pp. 487–488, 1984.
E. Stewart, D. F. Brewster, and P. E. Bernstein, “Subcutaneous emphysema and pneumomediastinum complicating tonsillectomy,” Archives of Otolaryngology: Head and Neck Surgery, vol. 130, no. 11, pp. 1324–1327, 2004.
Samir Yelnoorkar and Wolfgang Issing Cervicofacial Surgical Emphysema following Tonsillectomy. Case Reports in Otolaryngology. Volume 2014 (2014), Article ID 746152, 2 pages

POST-OPERATIVE – Chapter 24

Syringomyelia – Diagnosed after a Spinal

A 27-year-old woman was posted for emergency caesarean section, indication being foetal distress. Her haemogram and renal functions were within normal limits. No history of hypertension or diabetes during pregnancy. No other significant medical or surgical history. She was taken up as ASA E2 under spinal anaesthesia.

Spinal anaesthesia was administered in sitting position, in the L3-L4 space, with 0.5% Bupivacaine 1.8ml, and Fentanyl 25 µg. It was given at the first attempt in midline, using a 26G Quinckes needle. No problems were encountered in the intraoperative period. Surgery was also uneventful, and patient was shifted to the ward after observing for one hour.

On the first postoperative day, she tried walking to the toilet and found that her left leg was unsteady. She was helped by her relatives in the room. The anaesthetist was called for an opinion. On examination, it was found that motor power on right lower limb was normal. On the left lower limb, power was 3/5. She also had numbness. The injection site on her spine appeared normal.

The obvious concern was any sort of neurological injury from spinal anaesthesia. The patient was informed about this and other possible causes of this weakness. She was sent for radiological investigation. CT scan of lumbar spine revealed syringomyelia. Patient was referred to a neurosurgeon for further management.

Discussion

It is worthwhile having an open mind and investigating thoroughly when a serious complaint such as leg weakness is present. It is important to clinch the diagnosis and manage appropriately as early as possible, for the benefit of the patient and the medical personnel involved. Any medical complaint from patient in immediate postoperative period must not be ignored.

The differential diagnosis in this patient included;

Transient or permanent neurological injury from procedure – needle, direct injection of local anaesthetic into the nerve
Local epidural/spinal hematoma compressing on unilateral spinal nerves causing spinal cord injury
Pre-existing conditions like subclinical myelopathy or neuropathy.

In this scenario, clinicians encountered a rare situation. In a patient presumed to be young and healthy, investigation for post caesarean section lower limb weakness, revealed a pre-existing

Syringomyelia is a progressive myelopathy characterised by cystic degeneration within the spinal cord. It causes neurological deficit. Trauma, tumours, and congenital defects are common causes. Symptoms may include pain, decreased sensation of touch, weakness, and loss of muscle tissue. The diagnosis is confirmed with a CT, myelogram or MRI of the spinal cord. The cavity may be reduced by surgical decompression.

Implications for anaesthetists

In known case of syringomyelia, commonest site is cranio-cervical junction, (Arnold Chiari malformation), Any stimulus that may cause raise in ICP, intraventricular pressures can aggravate size of the syrinx and hence the symptoms. When the pathology is closer to the bulbar area, respiratory compromise may be anticipated.

Any spinal manipulation that could increase intracranial pressure or reduce intra- spinal pressure and cause deterioration of neurological functions must be avoided.

Pre-existing spinal pathology increases the incidence of postoperative neurologicalisolated syringomyelia at lumbar level, most likely congenital.

References

Lee, T.T., G.J. Alameda, E. Camilo, and B.A. Green, Surgical treatment of post-traumatic myelopathy associated with syringomyelia. Spine, 2001. 26(24 Suppl): p. S119-27.
Nakanishi K, Uchiyama T, Nakano N, et al. Spinal syringomyelia following subarachnoid hemorrhage. J Clin Neurosci. 2012 Apr. 19(4):594-7. Cook TM, BJA 2009
M. Cook et al Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br. J. Anaesth. (2009) 102 (2):179-190.
Lakshmi Jayaraman, Nitin Sethi, Jayashree Sood, Anaesthesia for Caesarean Section in a Patient with Lumbar Syringomyelia. Brazilian Journal of Anesthesiology Volume 61, Issue 4, July–August 2011, Pages 469–473

POST-OPERATIVE – Chapter 25

Uvula – The Culprit for Postoperative Desaturation

Case 1

A 4-year-old child weighing 12 kg, presented with a foreign body in his nostril. He was clinically normal and investigations were within normal limits. He was induced with Thiopentone 50 mg and Scoline 20 mg IV, intubated with a size 4 cuffed tube, and the throat was packed.

The foreign bodies (3 groundnuts) were removed from the right nostril in less than five minutes. Child had good respiratory efforts. Throat pack was removed, and he was extubated. Before shifting, he developed stridor and his saturation began to drop to 95%. On turning to the recovery position, the stridor improved but did not completely disappear.

The child was well sedated; hence it was decided to do a quick check laryngoscopy to look for another foreign body, or gauze/clot, which is the commonest cause of airway obstruction during foreign body removal. But to our surprise, an oedematous and inflamed uvula was obstructing the airway.

4 mg of Dexamethasone was given, and oxygen administered. Child was turned to prone position. Within 10 minutes, he recovered completely.

Discussion

This could have developed while packing the throat, or while removing the pack. Throat pack placement and removal must be done under vision. Handling of the airway, especially in children must be very gentle.

It could also be due to an allergic reaction to any drugs administered, or reaction to the foreign body, hence no time must be wasted in using steroids at the earliest onset of signs and symptoms. Importance of viewing the larynx when there are signs of obstruction cannot be over emphasized.

Case 2

A 45-year-old male had undergone lobectomy for tuberculosis under general anaesthesia. On follow up in the PACU, he looked quite comfortable with a head up position and 4 litres oxygen on flow through nasal prongs. SaO2 was about 96%, BP 140/90 mm Hg, pulse rate of 88/minute. Blood had been sent for ABG and other investigations.

Suddenly, the patient started coughing violently and had breathing difficulty. On examination, his pulse rate went up to 130/min, and SaO2 started to drop to 85%. Oxygen flow was increased to 8 litres/minute. Patient was getting restless and agitated. Auscultation was difficult and no conclusive diagnosis could be made.

X-ray chest was quickly ordered and in the meantime 200 mg of Hydrocortisone was administered. The patient felt much better after that, breath sounds could now be heard and SaO2 improved. On examination of his oral cavity, there was a tear in his soft palate and his upper airway was oedematous. X-ray chest was normal.

The tear could have been a mild injury which occurred while changing the double lumen tube, which became worse due to violent cough. Here the diagnosis was tricky since it was a thoracic surgery and the first thought was towards a complication in the lung. Steroid was administered to tide over the crisis without any confirmatory diagnosis, and because patient would respond, even if it were bronchospasm.

Discussion

When there is difficulty in breathing in the immediate postoperative period all the possible causes must be ruled out without any delay. Steroids come in handy whatever be the cause, to tide over the crisis before arriving at a definitive diagnosis. A single dose of the steroid can do no harm even if it is really not indicated in a particular situation, and in fact, there is an emerging evidence of using dexamethasone even for post-operative pain relief.

Examination of the upper airway is as important as auscultation when there is any sign of airway obstruction. Investigations must follow clinical judgement and no time can be wasted in initiating the treatment, especially in situations which involve the airway, which is the mainstay of any anaesthesia practice.

References

Uvula necrosis—an unusual cause of severe postoperative sore throat bja.oxfordjournals.org/content/97/3/426.3.long by CJ Atkinson – 2006 –
Epiglottitis: Background, Etiology, Epidemiology – Emedicine emedicine.medscape.com/article/763612-overview Feb 8, 2017

The cases presented here are similar to Problem Based Learning (PBL). This gives a great scope for practical learning and understanding the subject of Anaesthesia since anyone reading this book can quickly relate to similar incidents in their practice and solve a problem as and when it arises.

Post-Operative Chapters 23-25