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LETTER TO THE EDITOR

Subcutaneous Emphysema Caused by Pulsatile Irrigation During Orthopedic Surgery

Department of Anesthesia, Japanese Red Cross Society, Wakayama Medical Center, Wakayama city, Japan, ohmori-a{at}wakayama-med.ac.jp

To the Editor:

Pulsatile irrigation provides effective wound care during orthopedic surgery (1). However, pulsatile irrigation pressure can damage tissues, particularly when wounds are fragile. We describe the case of a 55-yr-old man who had repeatedly undergone surgeries for intractable osteomyelitis of the right non-union humerus and who underwent curative surgery for his condition.

After induction of general anesthesia, a tourniquet on the upper arm was inflated to 300 mm Hg. After reducing the humerus, wound curettage was followed by pulsatile irrigation (Surgeplus; Stryker, Kalamazoo, MI) with 2 L of saline. Pulsatile irrigation was repeated immediately before wound closure. The tourniquet was deflated, and the patient awakened from anesthesia.

Routine postoperative examination revealed crepitus of the anterior chest. A chest radiograph revealed subcutaneous emphysema along the right major pectoral muscle (Fig. 1). There was no evidence of pneumothorax and pneumomediastinum. The emphysema disappeared on the second postoperative day without sequelae.

View larger version (125K): [in this window] [in a new window]   Figure 1. The anteroposterior chest radiograph represented the flat relief of the right pectoral muscle layer, indicating the air accumulation on the anterior surface of muscle. No signs of pneumothorax and pneumomediastinum were detected.

Reported causes of perioperative emphysema include tracheal laceration caused by endotracheal intubation (2), repeated vomiting (3), surgical maneuvers along the oral base (4), and gas leakage from a pneumoperitoneum (5,6). In our patient, the emphysema appeared to expand along the fascia layer of the right pectoral muscle, close to the surgical site. This finding, in conjunction with undetectable airway leakages such as pneumothorax and pneumomediastinum, suggests that pulsatile irrigation caused the emphysema.

Although subcutaneous emphysema per se is benign, we were worried that it might be associated with dissemination of contaminated tissue from the infected wound. Anesthesiologists and surgeons should recognize this uncommon complication.

References

1. Brown LL, Shelton HT, Bornside GH, et al. Evaluation of wound irrigation by pulsatile jet and conventional methods. Ann Surg 1978;187:170–3.[Web of Science][Medline]
2. Chiu CL, Ong GSY. Subcutaneous emphysema and pneumomediastinum after endotracheal anaesthesia. Ann Acad Med Singapore 2000;29:256–8.[Medline]
3. Irefin SA, Farid IS, Senagore AJ. Urgent colectomy in a patient with membranous tracheal disruption after severe vomiting. Anesth Analg 2000;91:1300–2.[Abstract/Free Full Text]
4. Pan PH. Perioperative subcutaneous emphysema: review of differential diagnosis, complications, management, and anesthetic implications. J Clin Anesth 1989;1:457–9.[Medline]
5. Pearce DJ. Respiratory acidosis and subcutaneous emphysema during laparoscopic cholecystectomy. Can J Anaesth 1994;41:314–6.[Web of Science][Medline]
6. Sumpf E, Crozier TA, Ahrens D, et al. Carbon dioxide absorption during extraperitoneal and transperitoneal endoscopic hernioplasty. Anesth Analg 2000;91:589–95.[Abstract/Free Full Text]

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