AJA Asian Journal of Anesthesiology

Advancing, Capability, Improving lives

Letter to the Editor
Volume 51, Issue 1, Pages 50
Parnandi Bhaskar Rao 1 , Pratheeba Natarajan 1 , Neha Singh 1 , Ramachandran Trichur Ramaswamy 1
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Outline



To the Editor,

We report a case of 45-year-old male ASA I patient with fracture dislocation of lower thoracic vertebrae, who was scheduled for posterior stabilization with pedicle screw fixation. His preoperative blood pressure (BP) was 132/78 (96) mmHg, heart rate (HR) 68 beats/min, and peripheral oxygen saturation (SpO2) 99%. The peak inspiratory pressure (PIP) was 17 cmH2O after tracheal intubation, which increased to 21 cmH2O after lying prone. After an hour of surgery, there was a sudden drop in SpO2 to 91%, and increases in PIP to 29 cmH2O and in ETCO2 to 43 mmHg. As there were a pleural tear at the surgical site and reduced air entry to the right, right-sided pneumothorax was suspected and confirmed with c-arm. Vital signs continued to deteriorate [BP of 98/54 (68) mmHg, HR of 88 beats/min, ETCO2 of 46 mmHg, and SpO2 of 89%]; to improve the situation, a 28F intercostal drainage (ICD) tube was inserted by an anesthesiologist via the fifth intercostal space along the posterior axillary line and directed cephalad into the right hemithorax under c-arm guidance. The surgical site was covered with a sterile adhesive drape during the thoracostomy procedure. Hemodynamic parameters were improved [SpO2 99%, HR 80 beats/min, BP 112/68 mmHg, PIP 21 cmH2O, and ETCO2 32 mmHg]. Surgery was recommended and went uneventfully. Afterwards the patient was discharged home smoothly.

Desaturation is a major perioperative life-threatening problem. When it occurs under anesthesia, the algorithm ABCD-A SWIFT CHECK can be applied effectively to uncover the cause.1 We experienced decreased saturation with rise in PIP and ETCO2, and reduced air entry to the right side, which helped us in excluding any obstruction or endobronchial intubation as the cause for the mishap. Lung pathologies such as bronchospasm, pneumothorax, pulmonary edema, etc. can mimic this situation; however, auscultatory findings, surgical factor, and c-arm evidence pointed toward a right-sided pneumothorax.

An ICD tube is usually inserted when it is either iatrogenic, traumatic or the patient is on mechanical ventilation or hemodynamically unstable.2 In our case, multiple factors were coexisting.

Although the usual recommended position of a patient for inserting an ICD tube is supine, a sitting or semirecumbent position can be adopted, depending on the urgency and need of the hour. We approached the pleural space through the posterior axillary line, with the patient in the prone position.

In addition to the possibilities of injuring the long thoracic nerve and excessive drainage in the posterior approach, prone position enhances the possibility of lung injury secondary to altered lung mechanics.345 In contrast, an experimental animal study has concluded that the prone posture reduces the chances of open pneumothorax.6 Therefore, further research is required to provide definitive information in this area.

We came across an intraoperative pneumothorax during spine surgery, which was managed with an ICD tube inserted along the posterior axillary line, with the patient in the prone position. A similar consideration is applicable to various other surgeries that are performed in the prone position, with the risk of developing pneumothorax.789 Additionally, an early and direct communication with the surgeon can help us get to the root of the problem, a fact that can never be ignored.


References

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3
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The prone positioning during general anesthesia minimally affects respiratory mechanics while improving functional residual capacity and increasing oxygen tension
Anesth Analg, 80 (1995), pp. 955-960
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Turk Neurosurg, 20 (2010), pp. 27-32
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M. Agah, M. Ghasemi, F. Roodneshin, B. Radpay, S. Moradian
Prone position in percutaneous nephrolithotomy and postoperative visual loss
Urol J, 8 (2011), pp. 191-196
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R. Petri, M. Zuccolo, M. Brizzolari, L. Rossit, A. Rosignoli, V. Durastante, et al.
Minimally invasive esophagectomy: thoracoscopic esophageal mobilization for esophageal cancer with the patient in prone position
Surg Endosc, 26 (2012), pp. 1102-1107

References

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