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Lee JE, Kim MJ. Hemodynamic derangement associated with tension pneumomediastinum during minimally invasive esophagectomy: A case report. Medicine (Baltimore) 2022; 101:e31420. [PMID: 36316887 PMCID: PMC9622717 DOI: 10.1097/md.0000000000031420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Surgery is the treatment of choice for esophageal cancer. Since the 1990s, minimally invasive esophagectomy (MIE) has been developed using videoscope. Although MIE lowers mortality by reducing postoperative complications, the risk of carbon dioxide (CO2) insufflation related complications still exists. PATIENT CONCERNS A 56-years-old male patient underwent elective MIE. The patient (body mass index, 15 kg/m2) had well-controlled hypertension, cardiomegaly, and severe emphysematous lungs. He had iatrogenic pneumothorax during central venous catheterization 3 weeks prior; however, the pneumothorax was resolved before surgery. DIAGNOSIS During thoracoscopic surgery, respiratory acidosis was not corrected despite rapid respiratory rate and positive end-expiratory pressure. Intrathoracic CO2 pressure was lowered from 12 to 8 mm Hg, and laparoscopic surgery was performed through the diaphragm in the reverse Trendelenburg position. In 15 minutes at this position, pulseless electrical activity with respiratory failure and high peak inspiratory pressure developed. INTERVENTIONS CO2 insufflation was stopped and drained as soon as hypotension developed. The patient was placed in the supine neutral position, and cardiopulmonary circulation was restored without further treatment. OUTCOMES After the pneumomediastinum event, surgery was successfully performed. Respiratory acidosis due to CO2 insufflation was not corrected during surgery and the patient was transferred to intensive care unit without extubation. After 14 days, the patient was discharged without cardiopulmonary complications. However, the patient expired 2 years later due to cardiovascular disease. LESSONS In MIE, there is always a risk of catastrophic tension pneumomediastinum along with intravascular volume depletion, surgical position, and ventilatory strategy depending on the surgical characteristics.
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Affiliation(s)
- Jeong Eun Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
- * Correspondence: Jeong Eun Lee, Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 807, Hoguk-ro, Buk-gu, Daegu, Daegu 41404, Republic of Korea (e-mail: )
| | - Myeong Jin Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
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Bonardi CM, Spadini S, Fazio PC, Galiazzo M, Voltan E, Coscini N, Padalino M, Daverio M. Nontraumatic tension pneumopericardium in nonventilated pediatric patients: a review. J Card Surg 2019; 34:829-836. [PMID: 31269314 DOI: 10.1111/jocs.14159] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND AIMS Pneumopericardium is a rare air leak syndrome caused by the abnormal presence of air in the pericardial sac, with a high risk of morbidity and mortality. It is clinically divided into nontension and tension pneumopericardium, with the latter resulting in a decreased cardiac output and circulatory failure. There are limited data regarding nontraumatic pneumopericardium in nonventilated pediatric patients. Therefore, we aimed to describe a case of tension pneumopericardium and review the available literature. METHODS Case report and literature review of nontraumatic pneumopericardium in nonventilated pediatric patients. RESULTS A 2-month-old infant developed cardiac tamponade secondary to tension pneumopericardium 11 days after cardiac surgery promptly resolved with pericardium drainage. We reviewed the literature on this topic and retrieved 50 cases, of which 72% were nontension whereas a minority were tension pneumopericardium (28%). Patients with tension pneumopericardium were mostly neonates (35.7% vs 22.2%), presented with an isolated air leak (64.3% vs 36.1%), and had a history of surgery (28.6% vs 8.3%) or hematological disease (28.6% vs 11.1%). In all nontension cases, treatment was conservative, whilst in all other cases, pericardiocentesis/pericardium drainage was carried out. There was a high survival rate (86.0%), which was lower in patients with tension pneumopericardium (71.4% vs 91.6%). CONCLUSIONS Pneumopericardium is a rare condition with a higher mortality rate in patients with tension pneumopericardium, which requires immediate diagnosis and treatment. In nonventilated patients, tension pneumopericardium occurred more frequently in neonates, as an isolated air leak, and in those with a history of surgery or hematological disease.
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Affiliation(s)
- Claudia M Bonardi
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Silvia Spadini
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Paola C Fazio
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Moreno Galiazzo
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Elena Voltan
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Nadia Coscini
- Department for Community Child Health, Royal Children's Hospital, Melbourne, Australia
| | - Massimo Padalino
- Department of Cardiac, Thoracic and Vascular Sciences, Pediatric and Congenital Cardiac Surgery Unit, University of Padua, Padua, Italy
| | - Marco Daverio
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
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3
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Abstract
New additional risks factors that may act to increase the risk of subcutaneous emphysema include total gas volume, gas flow rate, valveless trocar systems, and robotic fulcrum forces. Background: Subcutaneous emphysema and gas extravasation outside of the peritoneal cavity during laparoscopy has consequences. Knowledge of the circumstances that increase the potential for subcutaneous emphysema is necessary for safe laparoscopy. Methods: A literature review and a PubMed search are the basis for this review. Conclusions: The known risk factors leading to subcutaneous emphysema during laparoscopy are multiple attempts at abdominal entry, improper cannula placement, loose fitting cannula/skin and fascial entry points, use of >5 cannulas, use of cannulas as fulcrums, torque of the laparoscope, increased intra-abdominal pressure, procedures lasting >3.5 hours, and attention to details. New additional risk factors acting as direct factors leading to subcutaneous emphysema risk and occurrence are total gas volume, gas flow rate, valveless trocar systems, and robotic fulcrum forces. Recognizing this spectrum of factors that leads to subcutaneous emphysema will yield greater patient safety during laparoscopic procedures.
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Affiliation(s)
- Douglas E Ott
- Biomedical Engineering, Mercer University, 109 Preston Court, Macon GA 31210, USA.
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Saggar VR, Singhal A, Singh K, Sharma B, Sarangi R. Factors Influencing Development of Subcutaneous Carbon Dioxide Emphysema in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair. J Laparoendosc Adv Surg Tech A 2008; 18:213-6. [DOI: 10.1089/lap.2007.0089] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Ashish Singhal
- Department of Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Karanvir Singh
- Department of Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Bimla Sharma
- Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India
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5
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Abstract
The frontiers of laparoscopic surgery have extended from gynecologic procedures to general surgical techniques. As new applications for laparoscopy emerge, anesthesiologists must be familiar with the possible complications associated with the various laparoscopic procedures. Only by an appreciation of the potential complications of a procedure can their overall incidence be minimized. A systematic approach must consider all potential complications during laparoscopy. In addition to routine evaluation (i.e., depth of anesthesia and volume status), anesthesiologists must confirm that intra-abdominal pressure is less than 15 mm Hg, and that inadvertent endobronchial intubation, pneumothorax, and gas embolism have not occurred. In the case of precipitous changes in vital signs not responding to routine management, it is imperative to release the pneumoperitoneum and place the patient in the supine (or Trendelenburg) position. After cardiopulmonary stabilization, cautious slow reinsufflation then can be attempted. With persistent signs of significant cardiopulmonary impairment, however, it is sometimes necessary to convert to an open procedure.
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Affiliation(s)
- G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas, USA.
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7
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Richard HM, Stancato-Pasik A, Salky BA, Mendelson DS. Pneumothorax and pneumomediastinum after laparoscopic surgery. Clin Imaging 1997; 21:337-9. [PMID: 9316753 DOI: 10.1016/s0899-7071(96)00086-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pneumothorax, pneumomediastinum, pneumopericardium, and subcutaneous emphysema have been described as complications of laparoscopy. This study evaluates the incidence and significance of these extra alveolar collections of air. We found that pneumomediastinum with or without pneumothorax was not associated with significant morbidity and is more likely after laparoscopic fundoplication than other laparoscopic surgeries. The presence of pneumomediastinum after fundoplication is a normal finding. However, pneumothorax has clinical significance and should be considered pathological.
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Affiliation(s)
- H M Richard
- Department of Radiology, Mount Sinai Hospital, New York, New York 10029, USA
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Capizzi PJ, Martin M, Bannon MP. Tension pneumopericardium following blunt injury. THE JOURNAL OF TRAUMA 1995; 39:775-80. [PMID: 7473976 DOI: 10.1097/00005373-199510000-00033] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pneumopericardium caused cardiac tamponade in a patient who was struck in the chest by a motor vehicle. Subxiphoid pericardial window and pericardial drainage successfully treated this condition. Diagnosis of this rare form of tamponade depends on clinical examination supported by chest radiographic findings.
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Affiliation(s)
- P J Capizzi
- Department of Surgery, Mayo Clinic, Rochester MN 55905
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Wolf JS, Stoller ML. The physiology of laparoscopy: basic principles, complications and other considerations. J Urol 1994; 152:294-302. [PMID: 8015056 DOI: 10.1016/s0022-5347(17)32724-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- J S Wolf
- Department of Urology, University of California School of Medicine, San Francisco 94143-0738
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10
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Overdijk LE, Rademaker BM, Ringers J, Odoom JA. Laparoscopic fundoplication: a new technique with new complications? J Clin Anesth 1994; 6:321-3. [PMID: 7946369 DOI: 10.1016/0952-8180(94)90080-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We report pneumomediastinum, pneumopericardium, and subcutaneous emphysema occurring in patients who underwent laparoscopic fundoplication in our clinic. These complications might adversely affect hemodynamics during this procedure.
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Affiliation(s)
- L E Overdijk
- Department of Anesthesiology, Academic Medical Center, Amsterdam, Netherlands
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Barba MA, Saez L, García-Molinero MJ, Aguilera M. Pneumopericardium without subcutaneous emphysema, pneumomediastinum, or pneumothorax after laparoscopy. Gastrointest Endosc 1993; 39:740. [PMID: 8224717 DOI: 10.1016/s0016-5107(93)70248-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Farmer KC, Tjandra JJ, Hockenberry S, Fazio VW. Pneumomediastinum following transanal excision of a rectal tumour. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1993; 63:568-71. [PMID: 8317987 DOI: 10.1111/j.1445-2197.1993.tb00456.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A 45 year old male underwent full thickness transanal excision of a recurrent rectal villous adenoma. On the evening of surgery he developed an unexplained fever of 38.9 degrees C. Plain X-rays revealed a significant pneumomediastinum and pneumoretroperitoneum. This was thought to be due to passage of intrarectal air into the mesorectum and extravasation along tissue planes. The patient was managed with restricted fluids by mouth, an antidiarrhoeal agent, intravenous antibiotics, and frequent clinical and radiological observations. During the following 48 hours the fever settled and the pneumomediastinum resolved by the tenth postoperative day. Sigmoidoscopic examination at this time showed a healing rectal wound. This case illustrates a potential consequence of pelvic surgery and emphasizes the extent of the visceral space that exists as a continuum between the pelvis, abdomen, thorax and neck. This is an unusual complication with a dramatic radiological appearance, but one that can be managed successfully with expectation of a completely benign course.
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Affiliation(s)
- K C Farmer
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio
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KAVOUSSI LOUISR, SOSA RERNEST, CAPELOUTO CARL. Complications of Laparoscopic Surgery. J Endourol 1992. [DOI: 10.1089/end.1992.6.95] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Affiliation(s)
- J K Lew
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, N.T., Hong Kong
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15
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Abstract
This case report describes a rare but potentially serious complication of pneumopericardium occurring during diagnostic laparoscopy. Contributing factors and possible etiologies are discussed.
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Affiliation(s)
- G B Knos
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
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16
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Robinson MD, Markovchick VJ. Traumatic tension pneumopericardium: a case report and literature review. J Emerg Med 1985; 2:409-13. [PMID: 4086777 DOI: 10.1016/0736-4679(85)90249-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A 39-year-old male arrived in the emergency department with multiple stab wounds to the chest. A pneumopericardium was present on initial chest x-ray study. He subsequently developed hypotension, tachycardia, an elevated CVP (36 cm H2O) and a pulsus paradoxus. All parameters improved following removal of 100 cc of air by pericardiocentesis. The etiology, diagnosis, pathophysiology, and treatment of tension pneumopericardium are discussed.
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