POST-OPERATIVE Chapter 5

Vasanthi-Vidyasagaran

Chest X-ray for Neck node biopsy – NPPE

Dr. Vasanthi Vidyasagaran*

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

*Correspondence: Vasanthi.vidyasagaran@gmail.com

A 30-year-old lady was posted for a neck node biopsy under day care Anaesthesia.

She gave history of swelling in left side of neck for three months, initially only palpable, gradually increasing in size. No history of cough or breathing difficulty. Biopsy was planned under general anaesthesia for two reasons:

  1. Deep seated node
  2. Patient preferred general anaesthesia.

On examination the patient was afebrile, vital parameters normal. Airway was normal with MPC 2. Chest was clear. Hb and PCV were within normal limits. Chest x-ray and ECG were not done.

She was premedicated with inj. glycopyrrolate 0.2 mg and inj. midazolam 1 mg, induced with fentanyl 100 mic and propofol 100 mg, intubated with atracurium 30 mg and maintained with N2O, O2 and sevoflurane 1 %.

The surgery was uneventful and the node procured without any difficulty.

At the end of surgery after about 45 minutes, she was reversed and extubated after complete neuromuscular recovery.

Immediately after extubation, she had jerky breathing, frothing at the mouth and began to desaturate. On auscultation, bilateral crepitations were heard and a diagnosis of pulmonary oedema was made. Inj. lasix 40 mg was given and she was immediately reintubated and ventilated with PEEP. Lungs cleared within 15 mins and she could be extubated without any further problems.

Patient was shifted to post-operative critical care unit. CPAP was applied for about half an hour. A post op chest X-ray showed quite a significant mediastinal widening. On follow up with a CT scan, multiple large mediastinal lymph nodes were noted compressing on the main bronchus. She was referred to hematologist and medical oncology for further diagnosis and management.

This was a case of non-cardiogenic pulmonary oedema, probably negative pressure pulmonary oedema, which typically happens as a complication at extubation.

Discussion

Was it a case of airway obstruction leading to pulmonary oedema causing hypoxia or hypoxia from airway obstruction causing neurogenic pulmonary oedema? Either way patient should be re intubated and given oxygen, positive pressure ventilation and supportive management. Since they usually have no primary cardiac or pulmonary pathology, these patients recover fast.

It may sometimes be a result of inadequate reversal (short procedure with intermediate acting muscle relaxant). We do not always have a nerve stimulator to check for adequate return of muscle power.

In patients being operated for lymph node biopsy, beware of enlarged nodes elsewhere. It is worthwhile eliciting history of symptoms from airway compression preoperatively.

Chest X ray is warranted in patients admitted for neck node biopsy, whether they are of infective cause or malignancy.

Contrary to the current recommendation that day care surgery does not require any investigations (except Hb for a woman in reproductive age), it is worthwhile to ask for specific investigations as per suspicion. This will ensure safety for both the doctor and the patient. Thus, a preop chest X-ray may have prevented the complication.

Reference

  1. Millers text book of anaesthesia.
  2. Balu, Bhaskar and JohnF, Fraser Negative pressure pulmonary edema revisited: Pathophysiology and review of management. Saudi J Anaesth. 2011 Jul-Sep; 5(3): 308-313.
  3. Negative pressure pulmonary edema – Springer Link link.springer.com/content/pdf/10.1007/s00405-007-0379-9.pdf
  4. Jun 28, 2007 – In this article, we report three cases of negative pressure pulmonary edema (NPPE) diffuse bilateral infiltrates on chest X-ray.

POST-OPERATIVE – Chapter 6

Choice of Postoperative Analgesia in Obese Children Following Tonsillectomy-Fentanyl can be Fatal

A 6-year-old girl was posted for tonsillectomy. She weighed 35 kilograms. She had history of periodical snoring during sleep. Problem with airway was anticipated. She was fit otherwise and tonsillectomy had to be done, as it was quite enlarged, and causing upper airway obstruction. She was to be taken up under general anaesthesia.

Anaesthesia was induced with IV Propofol 80mgs, Fentanyl 30 mics and 25 mgs Atracurium. Bag mask ventilation was managed well with help of oropharyngeal airway. Endotracheal tube was secured without any difficulty. Ventilation throughout the procedure was uneventful. long acting opioids as analgesics were deliberately avoided. All other forms of analgesia, like IV paracetamol, and Diclofenac suppository and local anaesthetic infiltration in the tonsillar bed were given.

Child was woken up smoothly and extubation was done in left lateral position after ensuring no bleeding from surgical site with patient fairly awake and responsive, and was shifted to recovery in left lateral position and oxygen administered, at 3 litres/min.

Once fully awake, she started complaining of intolerable pain and was crying. She was an extremely fussy child and had almost all the modes of analgesia. To calm the patient and to provide good pain relief, IV Fentanyl 25 micrograms was given by a duty doctor on the floor. Child became quiet and started sleeping. However, within 5 minutes, the anaesthesiologist was called as she had become apnoeic and started to desaturate with no response to command. Pulse rate came down to 50 /min.

The anaesthetic team attended to the child and supported ventilation immediately with bag and mask with 100% Oxygen. She was shifted back to the OT and ventilation was continued. Oropharyngeal airway was in place until the child recovered completely. Spontaneous respiration resumed after about 7-8 minutes, and there was no further complication

Discussion

Intense postoperative monitoring is very important, especially in obese, and surgery involving the airway. It is imperative to ensure safety before discharge out of recovery area. These children are at an increased risk of problems occurring at any stage of the anaesthetic process, some of which may be potentially life threatening.

Obese children pose certain specific problems related to obesity as well as their age. Specific care must be given towards positioning, intravenous fluids administration, drug dosage, and post-operative care. They may need increased doses of opioids and anaesthesia to obtund sympathetic response. (For e.g. when we intend to produce hypotensive anaesthesia). This has to be balanced against residual effect in the post-operative period. Short acting agents are ideal to use in such situations.

Opioids and other sedative drugs must be administered only under the supervision of the anaesthetist and the patient needs to be appropriately monitored. There is a practice among anaesthesiologists to administer fentanyl just before shifting out of the O T to ensure adequate analgesia, but this may turn out to be dangerous if not monitored.

References

  1. El-Metainy S, Ghoneim T, Aridae E, Abdel Wahab M. Incidence of perioperative adverse events in obese children undergoing elective general surgery. Br J Anaesth 2011; 106:359-63.
  2. Smith HL, Meldrum DJ, Brennan LJ. Childhood obesity a challenge for the anaesthetist. Paediatr Anaesth2002; 12:750-61.
  3. Jan Owen, Rob John, Childhood obesity and the anaesthetist Contin Educ Anaesth Crit Care Pain (2012) 12 (4): 169-175.

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