Beware delayed upper airway obstruction after ...

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3. Lau HP, Lin TY, Lee YW, Liou WH, Tsai SK. Delayed airway obstruction secondary to inadvertent arterial puncture during percutaneous central venous ...
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Beware delayed upper airway obstruction after inadvertent carotid artery puncture Inadvertent puncture of the carotid artery is a recognised complication of cannulation of the internal jugular vein1,2. Bleeding from the puncture site can lead to airway compression, which may be life-threatening if not recognised. We report an 87-year-old patient who presented with a delayed airway obstruction due to haematoma development following inadvertent carotid artery puncture. Although the puncture occurred preoperatively, the airway obstruction did not develop until postoperatively in the recovery room. The patient was scheduled for repair of an intertrochanteric femoral neck fracture. Her medical KLVWRU\ LQFOXGHG K\SHUWHQVLRQ DWULDO ÀEULOODWLRQ DQG coronary heart disease. A small thyroid goitre was recognised during her preoperative examination. Her medication included aspirin, digitoxin, metoprolol and methizol. The last dose of aspirin (100 mg p.o.) was given nine hours before surgery. Clotting parameters and platelet count were normal. On arrival in the anaesthetic room, routine monitoring was initiated and general anaesthesia was induced. Intubation conditions were excellent (Cormack and Lehane grade I). After induction, right internal jugular vein cannulation was attempted using an 18 gauge cannula and a standard landmark guided technique. The aspirated blood appeared to be dark and not pulsatile, but it was not possible to feed the guidewire into the vessel. After two further attempts, WKHSURFHGXUHZDVDEDQGRQHGDQGÀUPSUHVVXUHZDV applied to the area to prevent haematoma formation. Surgery then commenced and was completed uneventfully after 120 minutes. Haemodynamics remained within the normal range throughout and there was no evidence of haematoma formation. Once the patient was awake she was extubated, which was accompanied by a cough and a brief period of hypertension (185/90 mmHg) but no haematoma formation. However, about 10 minutes after transfer to the recovery room, a massive swelling of the anterior neck developed. This was accompanied by increasing dyspnoea, desaturation, hypertension and tachycardia. Immediate re-intubation of the trachea was performed following a small dose of propofol without muscle relaxant. The laryngeal view was then Cormack and Lehane grade III. The swelling was suspected to be a haematoma after failed jugular venous catheterisation. For surgical decompression, the patient was transferred again to the operating theatre with stabilised haemodynamics. A pulsating bleeding source from the right common carotid artery ZDV LGHQWLÀHG DQG VXWXUHG 8QOLNH WKH SUHRSHUDWLYH

visual impression, the goitre was larger than expected and there was still a huge oedema of the neck region. The medical team decided to perform surgical tracheotomy to prevent further postoperative airway complications. The explanation for the delayed bleeding may have been the sudden increase of thoracic pressure by the cough while removing the tracheal tube and the sudden increase of blood pressure during the awaking process. These changes could have reinitiated the bleeding process of an already clotted carotid laceration. The abnormal bleeding could have been exacerbated by the recent aspirin therapy. The presence of the goitre may have increased the severity of the airway obstruction. Inadvertent puncture of the carotid artery without associated coagulopathy usually causes a self-limited haematoma contained by the carotid sheath. However, large haematomas may occur even if coagulation of the patients is normal, and this may be fatal if unrecognised3,4. We recommend that patients who have had or who may have had an inadvertent carotid artery puncture should be monitored closely for haematoma formation and that this monitoring should be extended into the recovery period and until the patients are fully awake. The development of a delayed haematoma in the presence of a goitre and impaired consciousness postoperatively increase the danger of airway obstruction5,6. M. F. STRUCK V. LIPPERT C. MÜLLER F. WERNICKE R. STUTTMAN Halle, Saale, Germany References 1. Polderman KH, Girbes AJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med 2002; 28:1-17. 2. Schummer W, Schummer C, Rose N, Niesen WD, Sakka SG. Mechanical complications of central venous cannulations by experienced operators: a prospective study of 1794 catheterisations in critically ill patients. Intensive Care Med 2007; 33:1055-1059. 3. Lau HP, Lin TY, Lee YW, Liou WH, Tsai SK. Delayed airway obstruction secondary to inadvertent arterial puncture during percutaneous central venous cannulation. Acta Anaesthesiol Sin 2001; 39:93-96. 4. Digby S. Fatal respiratory obstruction following insertion of a central venous line. Anaesthesia 1994; 49:1013-1014. 5. Silva FS. Neck hematoma and airway obstruction in a patient with goitre: complication of internal jugular vein cannulation. Acta Anaesthesiol Scand 2003; 47: 626-629. 6. Rose DK, Cohen MM, Wigglesworth DF, DeBoer DP. Critical respiratory events in the postanesthesia unit. Patient, surgical, and anesthetic factors. Anesthesiology 1994; 81:410-418. Anaesthesia and Intensive Care, Vol. 36, No. 4, July 2008