INTRA-OPERATIVE

Chapter 7

Be prepared even if it is Surgical Misdiagnosis – Aneurysm/Femoral hernia

Dr. Vasanthi Vidyasagaran*

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

*Correspondence: Vasanthi.vidyasagaran@gmail.com

Dr. Vasanthy Vidyasagaran Muralidharan

Anaemia or Hydrocele

Swelling in the femoral area

A 60-year-old woman presented to the emergency room with diffuse painful swelling in the femoral area. She had the swelling for nearly 10 years, slowly increasing in size, and developed severe pain over the last 24 h. She had no other comorbidities. It was diagnosed as an obstructed femoral hernia and case was booked as urgent surgery.

All her relevant investigations were within normal limits.

Patient was taken up for urgent surgery as ASA 1 physical status under general anaesthesia. Induction of anaesthesia was smooth and uneventful. On incision, there was a splash of blood, and the team was taken by shock and surprise that it was an aneurysm of the femoral artery. Blood bank was immediately alerted, and two units supplied. Fortunately, a vascular surgeon was available on call and arrived within few minutes to help the general surgeon. Aneurysm was repaired and patient recovered uneventfully.

Here was a case of misdiagnosis. The swelling was non-pulsatile and clinical presentation was misleading. The whole team reacted quickly. Blood was made available immediately, and the vascular surgeon reached without any delay and the situation was brought under control. Meanwhile the anaesthetist was maintaining haemodynamics with intravenous fluids. However, it could have been different if the vascular surgeon and adequate blood products were not available.

Discussion

We had a situation which was totally unanticipated and there could have been a massive blood loss and even death on the table, for no fault of on the part of the anaesthetist.

It must be borne in mind that in anaesthetic career, we may be left to deal with such scenarios and efficient management from anaesthetic side is essential to save the patient.

References

  1. Agarwal BB, Gupta MK, Agarwal S, et al. Spontaneous rupture of iatrogenic (post inguinal herniorrhaphy) venovenous malformation managed endoscopically. J Laparoendosc Adv Surg Tech A. 2008;18:80-3.
  2. Teodorescu VJ, Reiter BP. Common iliac artery pseudo aneurysm following inguinal hernia repair – a case report and literature review. Vasc Surg. 2001. 35;239-44.
  3. Flückiger R, Koella C, Huber A. True aneurysm of the femoral profunda artery. Vasa. 1996;25:279-86.

Surprises during anaesthesia and surgery are not uncommon.

Eternal vigilance is our motto. But reacting quickly when a situation arises is the very purpose of vigilance.

Chapter 8

Bradycardia in a child: Not due to Hypoxia!

An 8-year-old boy weighing 40 kg, with idiopathic kyphoscoliosis was posted for posterior spinal fusion from T1-T10 level. History revealed mild motor developmental delay since birth. During pre-surgical evaluation, chest was clear and all relevant blood investigations were within normal limits. X-Ray chest confirmed scoliosis and pulmonary function tests showed restrictive lung disease.

The child was induced with Thiopentone 150 mg and intubated with Succinylcholine 60 mg. His pulse was 87/min and BP was 100/70 mm Hg sa02 of 97%. A 50:50 mixture of oxygen and nitrous oxide was administered along with Sevoflurane 1%. His left radial artery was cannulated for invasive blood pressure monitoring and a central venous catheter was placed in his right internal jugular vein. Heart rate slowed down to 40/min.

The central venous catheter was pulled out 1 cm and injection Atropine 0.3 mg was administered. A quick fluoroscopic shot confirmed correct position of the catheter.

Bradycardia persisted with wide QRS complex and peaked T waves. Child was unresponsive to a second dose of Atropine. An ABG was taken which showed PaO2 = 220, PaCO2 = 40, pH = 7.35, Na = 138, and K = 7.4.

The child was managed with Glucose/Insulin infusion and Soda Bicarbonate 20 mg/kg. Injection Calcium Gluconate was administered for membrane stabilizing action. Heart rate improved to 80/min in half an hour. Surgery was deferred and patient was monitored in the theatre till the QRS morphology returned to normal. He started breathing spontaneously and was extubated successfully. Potassium levels were repeated the following day, and showed a value of 4.5 meq/L.

The hyperkalaemia was probably due to the use of Succinylcholine in a patient who had preoperative muscle weakness. Serum potassium increases by 0.5 mEq/L with a single dose, and may not be significant in normal patients. Succinylcholine was chosen since his weakness was mild and mask ventilation may be difficult due to kyphoscoliosis. Electrolyte levels were checked nearly one month ago and not on day of the procedure. Repeat electrolyte levels were not done as the weakness was mild and there was no obvious restriction in movement.

Bradycardia in a child does not always mean hypoxia, it can also indicate underlying electrolyte or acid base disorder. Unsuspected myopathy in a patient with kyphoscoliosis can contribute to hyperkalaemia, and is difficult to diagnose in a normal clinical setting.

However, it is no excuse not to have done the electrolyte levels just prior to anaesthesia in this patient, and it may be worthwhile doing an extra investigation rather than have an unexpected complication.

References

  1. Postoperative hyperkalemia. – NCBI. https://www.ncbi.nlm.nih.gov/pubmed/25698564 by T Ayach – 2015
  2. [2] Fluids, Electrolytes and Common Post Operative Problems www.mc.uky.edu/obg/divisions/gynonc/onc/Fluid%20&%20Electrolytes.

Do not hesitate to ask for relevant investigations when required.

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