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were not adequately warmed. The routine precautions taken such as covering the extremities with a sheet and warming the IV fluids were obviously inadequate. Severe hypothermia along with the extubation stress would have precipitated VF in our case. It is recognized that defibrillation of severely cold myocardium is difficult. The hypothermic heart may also be unresponsive to cardio‑active drugs and electrical pacing, but 55% of the case reports do however report successful defibrillation at a temperature less than 30°C.[3,4] The most effective re‑warming strategies include administration of warm humidified oxygen, warm IV fluids, warming mattress, peritoneal/pleural lavage with warm saline, extra‑corporeal blood warming and CPB. The factors that lead to a good outcome in our case are witnessed arrest, immediate CPR, continued CPR during the whole arrest time, brain‑protecting effects of hypothermia and simultaneous effective re‑warming therapy.[5]
Vijayakumar Marimuthu, G Amirtha Balaji, Nishkala Chandrasekar, Kusuma Mathai Department of Anesthesiology, Southern Railway Head Quarters Hospital, Ayanavaram, Chennai, Tamil Nadu, India Address for correspondence: Dr. Vijayakumar Marimuthu, F 112, 4th street, West Thanikachalam Nagar, Ponniamman Medu, Chennai, Tamil Nadu, India. E‑mail:
[email protected]
REFERENCES 1. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112:IV1‑203. 2. Farstad M, Andersen KS, Koller ME, Grong K, Segadal L, Husby P. Rewarming from accidental hypothermia by extracorporeal circulation. A retrospective study. Eur J Cardiothorac Surg 2001;20:58‑64. 3. Clift J, Munro‑Davies L. Best evidence topic report. Is defibrillation effective in accidental severe hypothermia in adults? Emerg Med J 2007;24:50‑1. 4. Thomas R, Cahill CJ. Successful defibrillation in profound hypothermia (core body temperature 25.6°C). Resuscitation 2000;47:317‑20. 5. Strohecker B, Parulski CJ. Frostbite injuries of the hand. Plast Surg Nurs 1997;17:212‑6. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.111882
A case of subcutaneous emphysema following post‑operative vomiting Sir, Post‑operative nausea and vomiting (PONV) is a common complication after general anaesthesia (GA), rarely it can cause life threatening complications such as subcutaneous emphysema (SCE), which can lead to airway compromise and necessitate intervention.[1] We describe a case of SCE neck, face and upper thorax, which developed 8 hours after Tympanoplasty under GA, following forceful vomiting. Early recognition and proper management is critical to prevent the progression.[2] A 49‑year‑old lady diagnosed with left chronic suppurative otitis media was posted for tympanoplasty under GA. She was a hypertensive on treatment, with no other comorbid conditions. Pre‑operative investigations were within normal limits. Following pre‑medication with Ondansetron 4 mg intravenous (IV), Thiopentone was used for induction of anaesthesia. Atraumatic intubation with no. 7.5 cuffed oral endotracheal tube was facilitated with Suxamethonium 75 mg IV. Anaesthesia was maintained with oxygen, nitrous oxide, Halothane and Vecuronium, and controlled ventilation using Bain’s circuit. Electrocardiogram, non‑invasive blood pressure, Peripheral oxygen saturation and end tidal carbon dioxide were monitored. Vecuronium top up was given based on the requirement. After completion of the procedure, neuromuscular blockade was reversed, trachea extubated and shifted to post‑anaesthesia care unit, where the patient was monitored for 2 hrs, then shifted to the ward. About 8 hrs later in the ward, patient had a bout of cough and forceful vomiting following which she developed swelling of the face and neck. She complained of difficulty in breathing and change of voice in the supine position. On examination, patient had swelling of the face, neck and upper part of the chest bilaterally with crepitus over the swelling. Respiratory rate was 20/min, bilateral air entry present, vitals stable, and cardiovascular system clinically normal. She was shifted to Intensive care unit, administered oxygen by mask in propped up position and observed for respiratory and cardiac distress. Neck X‑ray showed air pockets in the anterolateral
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aspect, suggestive of SCE [Figure 1], air pockets were seen in the chest X‑ray also. General surgeon was informed in view of possible intervention. As nil per oral status was advised patient was maintained on IV fluids along with IV antibiotics, analgesics, antiemetics and steroids. No dyspnoea, oxygen desaturation or haemodynamic instability noted. Patient showed significant improvement in 48 hrs. She was allowed to take liquids orally on the 3rd day, and shifted to the ward on the 4th day. Patient made an uneventful recovery with conservative management, hence discharged from the hospital on 8th post‑operative day. SCE is a common occurance following surgeries such as chest surgery, laparoscopy, cricothyrotomy and pneumonectomy. On infrequent occasions, the condition can result from dental surgery, usually due to use of high‑speed tools that are air driven.[2] It is a rare complication after endotracheal intubation, blowing of the nose and vomiting.[2] The cause for SCE after vomiting are possibly due to spontaneous rupture of esophagus, alveolar rupture, trauma to the trachea and hypo pharynx.[3] This report describes the development of SCE after PONV with satisfactory response to conservative management. Change of voice is reported to herald airway compromise, but our patient did not develop this because inhalation of oxygen has helped in absorption of subcutaneous air quickly.[4] Nil per oral status was beneficial indicating that there could have been a small esophageal tear.[5] The role of antibiotics and steroids is unclear in these cases.[2]
The exact source of air could not be established as patient’s relatives declined for further investigations such as computed tomography neck and thorax and oesophagogram. Small esophageal tear could have been the source of air leak. Root cause of the events was vomiting. Hence, there is a need to use antiemetics to prevent such complications in the post‑operative period. Early recognition and proper management is of utmost importance to prevent the progression.
S Shanbagavalli, Santosh Kumar Department of Anaesthesia, Dr. B. R. Ambedkar Medical College and Hospital, Bengaluru, Karnataka, India Address for correspondence: Dr. S Shanbagavalli, No. 1994, Saideep, Yellamma Temple Street, New Thippasandra, HAL 3rd Stage, Bengaluru ‑ 560 075, India. E‑mail:
[email protected]
REFERENCES 1.
Feely TW, Macario A. The post operative care unit. In: Miller RD, editor. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone; 2000. p. 2302‑23. 2. McKenzie WS, Rosenberg M. Iatrogenic subcutaneous emphysema of dental and surgical origin: A literature review. J Oral Maxillofac Surg 2009;67:1265‑8. 3. Movafegh A, Shoeibim G, Ghaffari MH. Severe neck and upper thoracic subcutaneous emphysema after post op vomiting. Acta Med Iran 2004;42:303‑6. 4. Vijayakumar B, Ganessan R, Anbalagan V. A case of severe subcutaneous emphysema in the post‑operative period following cleft lip surgery. Indian J Anaesth 2010;54:163‑5. 5. Harris R, Joseph A. Acute tracheal rupture related to endotracheal intubation: Case report. J Emerg Med 2000;18:35‑9. 6. Brauer RB, Liebermann‑Meffert D, Stein HJ, Bartels H, Siewert JR. Boerhaave’s syndrome: Analysis of the literature and report of 18 new cases. Dis Esophagus 1997;10:64‑8.
Although cases of Boerhaave’s syndrome, which is life threatening emergency (vomiting, chest pain and SCE) are reported in literature, isolated cases of SCE of the face and neck after PONV appear to be rare.[6]
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DOI: 10.4103/0019-5049.111883
Azygous vein rupture after right internal jugular vein cannulation: A rare complication Sir, Figure 1: Soft‑tissue swelling in anterolateral aspect of neck with air pockets, suggestive of subcutaneous emphysema Indian Journal of Anaesthesia | Vol. 57| Issue 2 | Mar-Apr 2013
Catheterisation of the internal jugular vein (IJV) 215
