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[yogenbhatt1]

Read This:
21 yr male, Fall from height, fracture L-1 spine with paraplegia.
All investigations normal. Posted for instrumentation under GA in Prone.
Standard induction with Propofol, Fentanyl, Medaz, Roc intubation, Venti with Gas Oxygen and Iso as needed. Well controlled BP.
Goes on nicely for 100 mins. At this the surgeons drill and put a screw at T 11. The ventilation became difficult, taken over hand ventillation, but desaturates. The surgical team complains about air bubbles in the field of surgery. BP started dropping and the ECG showed patterns. Leading to a flat line.
Pt was made supine and CPR started. Recovered after a DC shock.
On observation, there was a great surgical emphysema all over the body from Eyes to Knee and elbows. few needle punctures were made all over, the patient, gradually sattled. Surgery was finished in lateral position and he needed Dopamine support for a while , patient was reversed and  was allowed to go to ICCU with a T- Piece and oxygen.
Portable X ray did not show any tension pneumo after he improved. (now atleast). There was surgical emphe all over in the X ray.
Patient regained full consciousness in next 36 hrs and was extubated.
Our impression on the spot was that either there was some rent in the trachea or some trauma in the lungs during the surgery.
There was no sign of trauma to trachea, no blood in ET tube or throat pack,. No gas in the mediastinum on X ray . Can it be from surgical field???
I am at loss on ideas now. Make geusses.

[jafo1964]

Obviously air has got into the fascial planes and has been driven in by high pressure and hence the extensive distribution of subcutaneous emphysema
We just need to figure out the route

The patient had hypotension, increased airway pressure, desaturation and asystole and was revived - so there was a correctable cause for that scenario of events that is why he survived

The commonest cause that fits into this clinical picture is a major pneumothorax progressing probably to tension pneumothorax.

So where did the pneumothorax occur from?
That is open to speculation!
During the fall he had a puncture wound into his lungs. Was asymptomatic till he was on spontaneous ventilation, the moment IPPV was initiated under anaesthesia patient developed slowly progressive pneumothorax progressing to the situation cited.

Alternatively operation around T11, the surgeons were very close to the posterior reflection of the pleura. They could have produced an inadvertent damage to the pleura during dissection or drilling which progressed to tension pneumothorax and arrest.

Air embolism can occur in spinal surgeries and can produce hypotension, increased airway pressure and asystole, but however it cannot produce such severe subcutaneous emphysema. So that kind of rules it out. Also massive air embolism producing arrest has a poor response to treatment.

Tracheal rent, although a possibility, seems far fetched and unlikely. There seems to be no airway instrumentation and intubation seems to have proceeded quite uneventfully.

Whatever be the cause of this catastrophe the anaesthetic team needs to appreciated for monitoring the patient effectively, picking up the life threatening complication in time, intervening appropriately and saving themselves and the patient from disastrous consequences. Commendation to all involved.

Finally inspite of our best intentions and attempts so many things seem to remain beyond our control in anaesthesia. Complications - expected or unexpected, are going to continue to occur and we just have to make sure that our monitoring and record keeping is as fool proof as possible, all necessary and practicable protocols are in place and above all Providence continues to shower his blessings on us

keep the good show going.

regs

[yogenbhatt1]

Thanks a lot on behalf of the whole team that was present there.
I like your replies, as they are always sounding logical and scintific.
A small point to correct, the venti and IPPV was on right through the surgery after induction. He was never on spontanious respiration. It all started suddenly after about 2 hours.
Unfortunately a spine surgery patient is in Prone position and so very well covered and with a curtain, that nothing was seen before the monitors started alarming.

[jafo1964]

A samll puncture wound into lung during fall sets up the source of pneumothorax.
Since patient is spontaneously breathing the intra-pleural pressures are negative and they are driving the ventilation, so no leak of air or pneumothorax occurs.
As soon as you started anaesthesia and initiated IPPV the  positive pressure now drives the ventilation. With each IPPV breath a small amount of air leaks into the pleural space. This small leak is repeated every breath and can eventually lead to pneumothorax and tension pneumothorax.
So that is why it can still take 2 hours of IPPV before the incident occured

ofcourse just thinking aloud

regs

[rs_shadow0000]

Alternatively operation about T11, the surgeons were actual abutting to the after absorption of the pleura. They could accept produced an careless accident to the pleura during anatomization or conduct which progressed to astriction pneumothorax and arrest, Surgical instruments.