Cardiac arrest caused by contralateral tension pneumothorax during one-lung ventilation: - A case report

Contralateral Tension Pneumothorax in One-Lung Ventilation: A Case Report and Systematic Review

Contralateral tension pneumothorax is a rare but fatal complication of one-lung ventilation. The life-saving decompression of pleural space was frequently delayed by the difficult confirmation of diagnosis because of general anesthesia that masks specific clinical presentations when the patient is alert. We reported a case of tension pneumothorax in a patient who underwent thoracic spine instrumentation. There were no contralateral tension pneumothorax cases on file from the search of the Anesthesia Quality Institute Closed Claims Database from 2001 to 2017. We systematically searched PubMed, Ovid MEDLINE, Embase, and Google Scholar. Over the past 30 years, there were 21 single case reports and two case series were retrieved. It was a consensus that difficult confirmation of the diagnosis of contralateral tension pneumothorax is the culprit of delayed life-saving intervention. Difficulty of oxygenation with increasing inspiratory pressure was usually the first sign suggesting contralateral pneumothorax; however, earlier presentations of cardiovascular system failure than respiratory failure have significantly increased the incidence of cardiac arrest and death. It is paramount to maintain a high suspicion of tension pneumothorax. The application of esophageal stethoscope, lung ultrasound, and simulator training may improve the chance of early diagnosis and patient outcome.

A Retrospective Analysis of Needle Thoracostomies at a Tertiary Level 2 Trauma Center

BACKGROUND

A tension pneumothorax is a condition that results in elevated pressure within the pleural space. The effective management of tension pneumothorax relies on needle decompression, commonly performed at the second intercostal space (ICS) midclavicular line (MCL). However, some literature suggests that catheters placed in the second intercostal space midclavicular line are prone to higher failure rates compared to the fifth intercostal space midaxillary line (MAL) (42.5% versus 16.7%, respectively). In this study, we aim to identify and scrutinize the prevalence of prehospital needle decompression from one tertiary care center over eight years and examine their trends, efficacies, or pitfalls. It is hypothesized that preclinical providers are performing needle decompression prematurely and unnecessarily.

METHODS

A set of 90 patient records obtained using the trauma registry at Saint Francis Hospital, Tulsa, Oklahoma, were retrospectively reviewed to evaluate the management and outcomes of tension pneumothorax, as well as the indications documented for needle decompression. Patient charts were reviewed via Epic Hyperspace (Epic, Madison, WI). The Oklahoma Emergency Medical Service Information System (OKEMSIS) also provided information contributing to the sample population.

RESULTS

The most documented indications for needle decompressions included diminished or absent breath sounds (52.70%), hypoxia (15.54%), hypotension, and hemodynamic instability (6.76%). Emergency medical services (EMS) reported improvements in 51 (56.67%) patients after needle thoracostomy. Improvements in vital signs after needle decompression were sporadic. The most common complication was catheter dislodging, which occurred most in the second intercostal space midclavicular line. Only nine patients had an oxygen saturation (SpO2) below 92% and a systolic blood pressure (SBP) below 100 mm Hg prior to receiving needle decompression.

CONCLUSION

Current practices for tension pneumothorax show little improvement in vital signs before and after needle decompression. Vital signs prior to needle decompression often do not indicate tension pneumothorax physiology. Preclinical providers may be inappropriately performing needle decompressions, an invasive procedure with complications.

Considerations of single-lung ventilation in neonatal thoracoscopic surgery with cardiac arrest caused by bilateral pneumothorax: A case report

BACKGROUND

Tension pneumothorax of the contralateral lung during single-lung ventilation (SLV) combined with artificial pneumothorax can cause cardiac arrest due to bilateral pneumothorax. If not rapidly diagnosed and managed, this condition can lead to sudden death. We describe the emergency handling procedures and rapid diagnostic methods for this critical emergency situation.

CASE SUMMARY

We report a case of bilateral pneumothorax in a neonatal patient who underwent thoracoscopic esophageal atresia and tracheoesophageal fistula repair under the combined application of SLV and artificial pneumothorax. The patient suffered sudden cardiac arrest and received emergency treatment to revive her. The recognition of dangerous vital sign parameters, rapid evacuation of the artificial pneumothorax, and initiation of lateral position cardiopulmonary resuscitation while simultaneously removing the endotracheal tube to the main airway are critically important. Moreover, even though the sinus rhythm was restored, the patient’s continued tachycardia, reduced pulse pressure, and depressed pulse oximeter waveform were worrisome. We should highly suspect the possibility of pneumothorax and use rapid diagnostic methods to make judgment calls. Sometimes thoracoscopy can be used for rapid examination; if the mediastinum is observed to be shifted to the right, it may indicate tension pneumothorax. This condition can be immediately relieved by needle thoracentesis, ultimately allowing the safe completion of the surgical procedure.

CONCLUSION

Bilateral pneumothorax during SLV combined with artificial pneumothorax is rare but can occur at any time in neonatal thoracoscopic surgery. Therefore, anesthesiologists should consider this possibility, be alert, and address this rare but critical complication in a timely manner.