Page 47 - Laparoscopic Surgery Online Journal

Suman Gupta et al

diaphragm which was found intact, the laparoscopic Reference is made to 4-point scale comparing varying
approach was abandoned and converted to conventional degrees of subcutaneous emphysema. 6
incision, which vented out the accumulated CO rapidly. • 0 = no subcutaneous emphysema
2
N O was stopped and was ventilated with 100% O . Arterial • 1 = mild emphysema with crepitus at trocar insertion
2
2
blood gas analysis showed pH: 7.26, PCO : 90 mm Hg, PO 2: sites or in the groin
2
80 mm Hg, HCO : 18 mmol/l. Vitals were monitored. • 2 = marked emphysema with crepitus extending to the
3
Injection mannitol 0.5 gm/kg IV was given in view of abdomen and thighs
suspecting raised intracranial pressure (ICP) because of • 3 = massive emphysema extending to the chest or neck
hypercarbia. After 15 to 20 minutes the subcutaneous and face.
emphysema started subsiding with EtCO approaching to
2 Our patient developed massive subcutaneous emphysema
near normal level. At the end of surgery, patient was reversed extending to chest, neck and face, resulting in difficulty in
for the residual neuromuscular blockade with injection ventilating the patient.
neostigmine 0.05 mg/kg and glycopyrrolate injection
Acute rise in EtCO and peak airway pressure was the
2
0.01 mg/kg. Trachea was extubated after the patient was
first indicator which signalled the occurrence of subcu-
fully awake and maintaining 100% saturation. Patient was
taneous emphysema. The resulting hypercarbia increases
shifted to postoperative ward and the postoperative stay of
the cardiac output, arterial blood pressure, ICP and
the patient was uneventful.
respiratory acidosis.
The management of subcutaneous emphysema during
DISCUSSION
laparoscopic procedure include hyperventilation, abandoning
With developing technology, laparoscopic procedures are the laparoscopic procedure, discontinuation of N O,
2
being frequently used worldwide, because of its minimal monitoring the vitals. Certain anesthetic recommendation
invasive nature of surgery, cosmetically better scar, early for the management of patient undergoing laparoscopic
postoperative recovery. Laparoscopic procedures have a procedure has been described. 7
positive overall economic benefit due to the shorter hospital 1. Monitoring of CO insufflation pressure (<12 mm Hg).
2
stays necessary for patients, compared with those 2. Routine and frequent examination and palpation of
undergoing open procedures. 4 In spite of all advantages
abdominal and chest wall to detect subcutaneous gas
laparoscopic procedures are not without complications. The
accumulation.
potential complications include subcutaneous emphysema,
3. Use of N O with caution.
2
pneumopericardium, pneumothorax, gas embolism, visceral 4. Adjusting the ventilation to an acceptable EtCO .
injuries. 2 Most commonly used among the gases for 2
5. Ruling out all other causes of subcutaneous emphysema
insufflation is CO , as it is readily available, low cost, a and acute hypercarbia.
2
high Ostwald’s B/G partition coefficient (0.48), and
odourless, inert, nonflammable, rapidly buffered in the body
CONCLUSION
by bicarbonate and excreted via lungs. But this aberrant
diffusible property of CO 2 is responsible for various Laparoscopic surgery represents a new challenge to the
complications. At rest, body cells consume 200 ml/min of anesthesiologist. A thorough concept of pathophysiological
5
O and produce same amount of CO . During insufflations changes during laparoscopy, strict monitoring and prompt
2 2
as much as 120 L can accumulate in the body during diagnosis and treatment of complications can result in
pneumoperitoneum. 1 positive patient outcome.
Subcutaneous emphysema is an uncommon complication
during laparoscopic procedure. It occurs when the REFERENCES
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2
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