GA2-61
Can You Transport My PSF Patient? A Case Report of Postoperative Cardiac Arrest Due to Large Pneumomediastinum Caused by Severe Bronchospasm
Zhang R, Dillow J, Coleman D, Antony A
University of New Mexico Hospital, Albuquerque, New mexico, United states
BACKGROUND
Tension pneumomediastinum leading to acute respiratory failure and subsequent cardiac arrest is an extremely rare and severe condition, and has not been previously described following posterior spinal fusion (PSF).
CASE DESCRIPTION
This is a 13-year old, 27.2 kg, female patient with neuromuscular scoliosis undergoing PSF. Following uneventful operation, normal CXR and extubation, she maintained a patent airway and adequate saturation. However, she had a persistent irregular respiratory pattern with wheezing bilaterally, and reintubation was required. She was then transported to the ICU on a dexmedetomidine infusion with ventilation by Ambu bag. During transport, airway resistance increased and it became increasingly difficult to ventilate the patient. Upon arrival to ICU, her arterial line tracing was flat, and CPR was initiated. Meanwhile, substantial subcutaneous emphysema was noted at the neck and chest, as well as facial and neck swelling. Tension pneumothorax (PTX) was suspected and bilateral needle thoracostomy for decompression was performed with significant air removed bilaterally. Return of spontaneous circulation and an adequate blood pressure was achieved within 2 minutes of decompression. A chest radiograph demonstrated pneumomediastinum and bilateral PTX. She was placed on the ventilator with PRVC, and norepinephrine infusion was started to support hemodynamics. She was extubated on POD 2 and d/c’d home on POD 5 with no other complications.
DISCUSSION
In this case, we suspect bronchospasm due to light anesthesia vs postop pulmonary changes occurred. Subsequent air trapping, elevated airway pressure, low pulmonary compliance with restrictive lung disease from scoliosis, and high pulmonary inflation pressure may worsen the condition. In addition to CPR, we disconnected the endotracheal tube from the Ambu bag to allow relief of excessive airway pressure, and subsequently performed gentle ventilation with a slower rate. We performed needle decompression for diagnosis and treatment. PTX with tension pneumomediastinum was likely the cause of her cardiac arrest.
Pneumomediastinum is associated with asthma, severe cough and vomiting, and forceful straining during exercise[1]. Although we did not administer muscle relaxant, no significant coughing was observed during transport. Case reports of perioperative acute pneumomediastinum are associated with difficult airway management with multiple intubation attempts[2]. Our intubation was smooth and no rigid stylet was used.
In conclusion, during transport of intubated patients, we should stay vigilant, ensure adequacy of sedation, and directly observe and monitor the airway pressure to avoid the occurrence of similar events.
REFERENCES
1. Banki, F., et al., Pneumomediastinum: etiology and a guide to diagnosis and treatment. Am J Surg, 2013. 206(6): p. 1001-6; discussion 1006.
2. Pandey, M., et al., Endotracheal intubation related massive subcutaneous emphysema and tension pneumomediastinum resulting in cardiac arrest. J Postgrad Med, 2003. 49(2): p. 188-9.
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