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PubMed1993

Subcutaneous emphysema, pneumomediastinum and pneumothorax complicating laparoscopic vagotomy. Report of two cases.

Two patients developed subcutaneous emphysema and pneumomediastinum during laparoscopic vagotomy. One of the patients also had a pneumothorax which produced a sudden increase in end-tidal carbon dioxide concentration preceding arterial oxygen desaturation. The pneumothorax was drained with an intercostal cannula. The patient required a twofold increase in minute ventilation to maintain normocarbia, probably because of the additional absorption of carbon dioxide through the pleural cavity. Despite the presence of a peritoneo-pleural communication, surgery was successfully completed. We believe that gas under tension in the peritoneal cavity dissected along tissue planes around the oesophagus opened up during surgery. Thus pneumomediastinum, subcutaneous emphysema and pneumothorax are definite risks associated with this new procedure.

Adult↗
PubMed1977

[Percutaneous implantation of permanent pacemakers (author's transl)].

2 methods for the implantation of permanent pacemakers with percutaneous puncture of the subclavian vein are described. The first one was used in 44 patients with the aid of an introducing catheter-set Desilets-Hoffman consisting of guide-wire, inner Teflon dummy catheter and outer thin-walled sheath; through this a shoulder-less electrode catheter no. 8 could be inserted for permanent pacing. The other technique was applied to 20 patients and used thinner special electrodes no. 6F, which could be introduced directly through a plastic cannula inserted with a puncture-needle. The advantages are: diminished risk of infections, local anesthesia instead of general anesthesia, applicability by the cardiologist in the catheterization-laboratory or under a simple fluoroscopy-unit, short stay of patients in the hospital without transfers to other departments, few personnel (1 scrubbed doctor, 1 non-scrubbed nurse), recognition of venous anomalies (singular left superior caval vein) without useless incisions for the patient. Complications such as pneumothorax, puncture of the subclavian artery, and dislocations of the electrodes have also been encountered.

Anesthesia, Local↗
PubMed1994

Physiological studies of thoracic spinocerebellar tract neurons in relation to respiratory movement.

The differential roles of thoracic spinocerebellar tract (SCT) neurons with axons ascending in ipsi- (uncrossed) and contralaterally (crossed) spinal cord and their activities during respiratory movement were examined by extracellular recordings in the T9-T12 spinal segments of the anaesthetized cat. A total of 36 uncrossed and 7 crossed SCT neurons showed rhythmic discharges in relation to either spontaneous or artificial respiration. Uncrossed neurons were located in and around Clarke's column and thus are cells of origin of the dorsal spinocerebellar tract (DSCT). Crossed neurons were located in laminae VII and VIII. Almost all DSCT neurons were modulated during artificial respiration. Nineteen DSCT neurons showed high-frequency discharges during chest expansion and 15 DSCT neurons showed high-frequency discharges during the chest retraction phase of artificial respiration. Their respiration-related activity maintained the same phase relation and firing patterns after vagotomy. The phase relationship of neural rhythmicity to chest movement during artificial respiration and spontaneous breathing was the same in 14 neurons examined. Artificially induced pneumothorax caused a marked decrease of respiration-related modulation, and severing of a single nerve to the appropriate muscle caused a marked decrease of modulation, suggesting that respiration-related rhythmic activity of DSCT neurons is induced by the extension of respiratory muscles in the chest wall during both spontaneous and artificial respiration. Crossed SCT neurons showed rhythmic activity in phase with the central respiratory rhythm as indexed by phrenic nerve activity. Two neurons received an excitatory influence and five an inhibitory influence in the inspiratory phase from the centre. Four neurons in the latter group also received excitatory inputs from the periphery during chest expansion. Since inspiration brings chest expansion during spontaneous breathing, the central and peripheral inputs seem antagonistic in function. These neurons seemed to signal a discrepancy between the chest wall movement and the central respiratory rhythm. Functional differences between uncrossed and crossed SCTs in the lower thoracic segments in regard to the central and peripheral inputs as observed here are similar to those observed in the lumbar SCTs during locomotion.

Animals↗
PubMed1985

[Open approach to the subclavian vein for permanent cardiac stimulation].

In 97.5% of 562 successive attempts, puncture of the subclavian vein to introduce permanent pacemaker electrodes was made easier and safer by the incisional technique described in this report. The very low incidence (0.35%) of traumatic pneumothorax and the absence, after a long follow-up, of any infection or exteriorization of the pacemaker chamber were the main advantages of this technical variant.

Catheterization↗
PubMed1980

[Subclavian route placement of electrodes for permanent stimulation].

The subclavian vein gives a rapid, direct approach to the right heart cavities. The pacing catheter was introduced via the subclavian vein in a series of 187 patients. A no. 9 Desilets and Hoffman percutaneous catheter introducer may be used with most types of pacing catheter, including bipolar models. Complications were rare : one case of pneumothorax was observed. The subclavian vein approach simplified the operative procedure of implantation and offers a useful alternative in difficult cases of reimplantation.

Female↗
PubMed2003

Pneumothorax during laparoscopy.

BACKGROUND: Pneumothorax is a known complication of laparoscopy, with most pneumothoraces diagnosed postoperatively with conventional chest x-ray. Electrocardiogram (ECG) conduction changes are associated with pneumothorax. In a sheep model, ECG changes were evaluated as a potential indicator of intraoperative pneumothorax. Additionally, resolution rates of helium (He) and carbon dioxide (CO2) pneumothorax were also evaluated in this model. METHODS: Under general anesthesia, 10 sheep had known volumes (20-100 cc) of either He or CO2 introduced into the left hemithorax. A 12-lead ECG recorded changes associated with the induced pneumothorax. After changes in the ECG plateaued, the gas volume in the hemithorax was increased to 2 L and the resultant pneumothorax was followed for a 2-h period using fluoroscopy to determine resolution rates for the different gas pneumothoraces. Gas volumes were aspirated after 2 h and ECGs were again recorded. RESULTS: Pneumothorax volumes as low as 20 cc produced consistent ECG changes. The amplitude of the precordial QRS complex was seen to diminish, and this lowering of the QRS amplitude continued as pneumothorax volume increased up to 100 cc. The ECG returned to prepneumothorax patterns with aspiration of the left chest. For different gas pneumothoraces, CO(2) pneumothorax showed almost complete resolution in the 2-h period, whereas He pneumothorax was unchanged. CONCLUSIONS: Precordial ECG changes appear to be a very sensitive indicator of pneumothorax, with very small pneumothorax (<100 cc) consistently being detected by reduction of the QRS complex amplitude. Intraoperative use of precordial ECG leads could result in rapid identification of pneumothorax during laparoscopic surgery. Carbon dioxide pneumothorax shows near 100% resolution in a 2-h period. This supports recommendations of expectant management in asymptomatic patients with CO(2) pneumothorax. However, He pneumothorax does not resolve spontaneously quickly and may require aspiration even in asymptomatic patients.

Absorption↗
PubMed1996

Pneumothorax complicating laparoscopic ureterolysis.

In a 71-year-old female marked left-sided ureteral stenosis secondary to retroperitoneal fibrosis was diagnosed. Since conservative therapy with cortisone had failed, laparoscopic ureterolysis was performed. Following tracheal intubation the lungs were ventilated with 40 vol% O2 in air and isoflurane 0.5-2%, using a positive end-expiratory pressure of 6 cm H2O. A CO2 pneumoperitoneum was established with a pressure-controlled high-flow insufflator; the intraabdominal pressure during the procedure was 14 mm Hg. Two hours after gas instillation, the peak airway pressure increased from 22 to 40 cm H2O, and the PaCO2 from 45 to 70 mm Hg. Breath sounds over the right lung were no longer heard, and subcutaneous emphysema was noted over the neck and face. An intraoperative chest X-ray confirmed a right pneumothorax. Following peritoneal gas evacuation, the PaCO2 returned to 35 mm Hg, the subcutaneous emphysema diminished, and a repeat chest X-ray showed complete resolution of the pneumothorax. The course of this event led us to the conclusion that the pneumothorax was due to diffusion of CO2 from the peritoneal to the pleural cavity through congenital defects in the diaphragm. Ureterolysis could be continued by laparotomy.

Aged↗
PubMed1998

Is tension pneumothorax a threat in trauma laparoscopy?

BACKGROUND: Tension pneumothorax is a reported risk with pneumoperitoneum in the presence of diaphragmatic injuries. A goat model with and without diaphragmatic injury was used to determine if varying levels of intra-abdominal pressure (IAP) result in tension pneumothorax. METHODS: Twenty-four goats were divided equally into four groups: (1) 5 mm Hg IAP control, (2) 15 mm Hg IAP control, (3) 5 mm Hg IAP with diaphragmatic injury, (4) 15 mm Hg IAP with diaphragmatic injury. Chest x-ray films were made and heart rate (HR), mean arterial pressure, central venous pressure (CVP), arterial blood gases, and airway pressure (AP) were measured at 10-minute intervals up to 30 minutes. Significant changes were determined by using the one-way analysis of variance and Mann-Whitney test with alpha set at p < 0.05. RESULTS: In group 4, 100% (all six goats) developed radiographic evidence of tension pneumothorax by 10 minutes. Mean changes from baseline at 20 minutes for the following parameters were all significantly different from controls: HR (p < 0.05), CVP (p < 0.0001), PaO2 (p < 0.001), and AP (p < 0.004). Mortality was 67% (four of six) at 25 minutes. In group 3, 100% (all six goats) of the animals developed radiographic evidence of a simple pneumothorax without mediastinal shift. In this group, there were significant changes in PaO2 (p < 0.003), AP (p < 0.04), and HR (p < 0.05). Mortality was 16% (one of six) at 25 minutes. CONCLUSION: In this goat model of diaphragmatic injury, tension pneumothorax is a significant threat when pneumoperitoneum is maintained at 15 mm Hg IAP. Pneumoperitoneum at 5 mm Hg IAP leads to simple pneumothorax with deleterious effects on oxygenation. Changes in AP, CVP, HR, and PaO2 provide early clues to the development of the problem.

Animals↗
PubMed1998

Complications of dual chamber pacemaker implantation in the elderly. Pacemaker Selection in the Elderly (PASE) Investigators.

Pacemakers are frequently implanted, yet accurate prospective data on implant complications are limited. Elderly patients may be at increased risk of implant complications and are increasingly being referred for pacemaker implantation. The purpose of the present analysis was to define the incidence and possible predictors of serious complications of dual chamber permanent pacemaker implantation in the elderly. Therefore, we sought to prospectively identify the incidence and predictors of pacemaker implant complications in a large multicenter trial involving patients receiving a dual chamber pacemaker. The Pacemaker Selection in the Elderly (PASE) study was a prospective trial designed to evaluate quality of life in dual chamber pacemaker recipients age 65 years or older randomized to DDDR versus VVIR programming. In addition to being age 65 years or older, patients enrolled in this study were in normal sinus rhythm, and had standard indications for permanent pacemaker implantation. All patients received dual chamber pacemakers and were randomized to DDDR versus VVIR pacing. Pacemaker implant complications were collected on standardized forms which were completed at pacemaker implantation and during follow-up appointments. In this study of 407 patients, there were 26 complications occurring in 25 patients (6.1%). The most frequent complication was lead dislodgment which occurred in 9 patients. This was followed by pneumothorax (8 patients) and cardiac perforations (4 patients). In 18 patients (4.4%) repeat surgical procedures (including chest tubes) were required. Complications were noted prior to discharge in only 18 patients. There were no significant predictors of overall complications. Pneumothorax was more frequent in patients > or = 75 years old, and was observed only in patients with subclavian venous access. In conclusion, complications from pacemaker implantation in the elderly are seen in 6.1% of patients and 4.4% of patients require a repeat surgical procedure. Other than advanced age and lower weight predicting for pneumothorax, there are no significant clinical predictors of complications.

Age Factors↗
PubMed2006

Intraoperative pneumothorax during laparoscopic cholecystectomy.

Anesthesiologists currently view laparoscopic cholecystectomy resemblant to other laparoscopic procedures with respect to the necessity of inducing a pneumoperitoneum via abdominal insufflation of carbon dioxide (CO2). The present case report describes a healthy 63-year-old man who while undergoing elective laparoscopic cholecystectomy under general anesthesia, developed hypoxemia in the course in consequence of pneumothorax. This complication, although rare, can be catastrophic if prompt diagnosis and rapid intervention and management do not come in the nick of time.

Cholecystectomy, Laparoscopic↗
PubMed1997

Delayed tension pneumothorax after laparoscopy.

Laparoscopy is a safe and useful procedure in evaluating intraabdominal disease. Serious complications have been reported but are rare. Laparoscopy related pneumothorax is one such complication that may occur during the procedure or in the immediate period thereafter. This complication is typically neither hemodynamically significant nor tension in nature. We report the unique case of a 52-year-old woman who not only developed acute respiratory compromise from a tension pneumothorax but did so 3 h after the completion of a seemingly uneventful laparoscopic procedure. Prompt recognition of this potential complication may permit immediate and effective treatment of this life-threatening complication.

Female↗
PubMed1990

Chest radiographs after permanent pacing. Are they really necessary?

The chest radiographs of 600 consecutive patients undergoing insertion of a permanent cardiac pacemaker were reviewed to determine the incidence and nature of abnormalities present. Abnormalities were detected on the chest radiographs of 131 patients (21.8%). Unsatisfactory electrode tip position and other features related to the electrode wire were commonest (14.4%). Complications related to the lungs and pleura were present in 5.5%, and those related to the generator and pouch least frequent (1.9%). Complications occurred more frequently following installation of a replacement system (48.3%) compared to new systems (17.2%). Important complications not initially detected included pneumothorax (8/15) and poor electrode loop (26/27). Chest radiographs following permanent cardiac pacing frequently demonstrate significant abnormalities whose detection is improved by awareness of their incidence and nature.

Diagnostic Tests, Routine↗
PubMed2001

Transient exit block of a DDD pacemaker with unipolar leads in subcutaneous emphysema following pneumothorax.

This case report describes a transient pacemaker exit block due to subcutaneous emphysema following pneumothorax. Pneumothorax after pacemaker implantation is rare, but development of subcutaneous emphysema under such circumstances is even more uncommon. Exit block develops only with the use of unipolar leads; with implantation of bipolar leads, this complication cannot occur.

Aged↗
PubMedDate not supplied

[Bilateral pneumothorax; a rare complication of gynecological laparoscopy (author's transl)].

A case with bilateral pneumothorax in association with laparoscopy is described. Several hypotheses could explain this rare complication. 1. It could be an association of the induced pneumoperitoneum and a bilateral pneumothorax due to rupture of both mediastinal pleurae or emphysematous bullae secondary to positive pressure ventilation during anesthesia. 2. The pneumoperitoneum could be directly related to the pneumothorax by subperitoneal air extension to both pleurae with secondary rupture. Less likely is the hypothesis in which a pleuro-peritoneal communication exists, whether congenital or acquired, on both halfs of the diaphragm.

Adult↗
PubMed1987

Iatrogenic trauma to the thorax.

With more sophisticated medical procedures and treatment for the critically ill patient, iatrogenic damage to the thorax has become increasingly common. But simple radiologic procedures, such as chest radiography and fluoroscopy, permit diagnosis of unsuspected and clinically silent complications. A very important iatrogenic trauma to the lung depends on the increasing use of overpressure ventilation. Experimental evidence shows that the lung can be damaged with interstitial emphysema at peak pressures as low as 40 cm H2O. The chest radiograph may show and early pathognomonic finding of perivascular air collections. The respirator treatment should then be modified to avoid pneumomediastinum and pneumothorax. The placement of catheters, chest tubes, endotracheal tubes, and feeding tubes as well as pacemaker electrodes and counterpulsation balloons may cause serious complications. Follow-up chest radiography after these procedures is therefore important.

Barotrauma↗
PubMed1993

Intraoperative complications of laparoscopic cholecystectomy.

We report a series of intraoperative complications of laparoscopic cholecystectomy. Three cases are presented in which subcutaneous emphysema associated with pneumomediastinum, pneumoscrotum, and pneumothorax with pneumomediastinum and ocular emphysema, respectively, developed intraoperatively. These events resulted in no major morbidity to these patients. Use of N2O and monitoring of airway and intraabdominal pressures are discussed.

Adult↗