Subcutaneous emphysema and buccopharyngeal submucosal emphysema after retroperitoneal laparoscopic surgery and upper airway obstruction

Abstract

Editor—Airway control is one of the most important tenets of anaesthetic practice. We report a case of buccopharyngeal submucosal emphysema and subcutaneous emphysema after retroperitoneal laparoscopic surgery, involving an iatrogenic upper respiratory obstruction and affecting respiration. A 55-yr-old man (ASA I) was undergoing a retroperitoneal laparoscopic unroofing of renal cysts. Renal cyst was documented on ultrasound study. The preoperative physical examination and laboratory examination were essentially normal. Anaesthesia monitoring consisted of ECG, peripheral pulse oxygen saturation (SpO2), arterial pressure (AP), and end-tidal carbon dioxide tension (PE′CO2). Anaesthesia was induced using fentanyl 0.3 mg, disoprofol 150 mg, and vecuronium 8 mg, and the trachea was intubated. Anaesthesia was maintained with sevoflurane, disoprofol, fentanyl, and vecuronium. The retroperitoneal clearance was insufflated with CO2 to a pressure of 14 mm Hg. During the anaesthesia and operative period, lasting nearly 230 min, the vital signs remained within normal limits. The PE′CO2 ranged from 4.0 to 7.5 kPa. The peak inspiratory airway pressure ranged from 18 to 33 mm Hg. After the end of the surgery, the tracheal tube was removed followed adequate reversal of muscle power. Soon thereafter, the patient started to snore and the SpO2 declined to 86%, PaCO2 increased. Using the jaw-thrust method and adopting mask pressure breathing assistor with high-flow oxygen immediately, SpO2 could be maintained at 95% level, but the patient still snored seriously. Physical examination showed that the patient could freely uplift his head for more than 5 s, and had a strong handshake with the normal train-of-four ratio. Although snoring persisted, the patient could not tolerate oropharyngeal airway. Marked subcutaneous crepitus was now obvious, especially in the area of the cheek, neck, chest, abdomen, and limbs. Subcutaneous emphysema was apparent. After monitoring NAP, heart rate, SpO2, and arterial blood gas analysis in the operating theatre, and using mask pressure breathing assistor with high-flow oxygen on and off for 2 h, the subcutaneous crepitus started to reduce significantly, and also the snoring started to resolve with the return of adequate breathing. The upper respiratory tract obstruction is a risk factor that may result in serious consequences. During the post-anaesthesia recovery period, many factors may lead to upper respiratory tract obstruction.1Xu Q Guo Q Yao S Wang G Clinical Anaesthesiology. People’s Medical Publishing House, Beijing2005: 163Google Scholar In this patient, retroperitoneal insufflated with CO2 induced buccopharyngeal submucosal emphysema, which was found after operation, led to respiratory tract obstruction. The reasons for buccopharyngeal submucosal emphysema and upper respiratory tract obstruction in this case could be the long time of retroperitoneum laparoscopic surgery, and high airway pressure. The E′CO2 increased implying CO2 absorption. The patient had no previous history of obstructive airway disease, and because the muscle power had returned to normal, the snoring could only be attributed to upper airway emphysema. According to reports in the literature, subcutaneous emphysema can lead to pneumopericardium and pneumomediastinum.2Santana A Crausman RS Dubin HG Late onset of subcutaneous emphysema and hypercarbia following laparoscopic cholecystectomy.Chest. 1999; 115: 1468-1471Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 3Ko ML Pneumopericardium and severe subcutaneous emphysema after laparoscopic surgery.J Minim Invasive Gynecol. 2010; 17: 531-533Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 4Dehours E Vallé B Bounes V Lauque D A pneumomediastinum with diffuse subcutaneous emphysema.J Emerg Med. 2012; (Advance Access published in April)doi:10.1016/j.jemermed.2011.08.023PubMed Google Scholar, 5Loughlin MT Duncan TJ Iatrogenic pneumomediastinum and subcutaneous emphysema as a complication of colonoscopy with cold forceps biopsy.Mil Med. 2012; 177: 474-476Crossref PubMed Scopus (2) Google Scholar, 6Falidas E Anyfantakis G Vlachos K Goudeli C Stavros B Villias C Pneumoperitoneum, retropneumoperitoneum, pneumomediastinum, and diffuse subcutaneous emphysema following diagnostic colonoscopy.Case Rep Surg. 2012; 2012: 108791PubMed Google Scholar In this case, maxillofacial subcutaneous emphysema was severe, and submucosal emphysema as a complication occurred at the same time. None declared.