Anesth Analg 2000;91:1300-1302
© 2000 International Anesthesia Research Society
CASE REPORTS
Urgent Colectomy in a Patient with Membranous Tracheal Disruption After Severe Vomiting
Samuel A. Irefin, MD*,
Ibrahim S. Farid, MD*, and
Anthony J. Senagore, MD
Departments of
*General Anesthesiology and
Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
Address correspondence and reprint requests to Samuel A. Irefin, MD, Department of General Anesthesiology E-31, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195. Address e-mail to Irefins{at}ccf.org
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Abstract
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Implications: We report a case of a patient who developed membranous tracheal disruption after severe vomiting. He subsequently required urgent colectomy for toxic megacolon under general anesthesia. With this challenging situation, we were able to successfully conduct general anesthesia in the presence of tracheal laceration, pneumothorax, and pneumomediastinum.
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Introduction
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Rupture of the tracheobronchial tree is a life-threatening condition. It is most common after blunt trauma to the neck and chest areas or after endotracheal intubation (1–3). One recent report described massive subcutaneous emphysema and airway compromise after vomiting as a result of alveolar rupture (4). In most of these cases resulting from esophageal rupture, patients subsequently developed Boerhaave’s syndrome (5–7). Boerhaave’s syndrome is the spontaneous rupture of the esophagus as a result of vomiting with the development of mediatinitis.
We report a case of a patient who developed membranous tracheal laceration after severe vomiting episodes. He subsequently required an urgent colectomy and presented a challenging intraoperative management problem.
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Case Report
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A 24-yr-old, 56-kg man with known history of mucosa ulcerative colitis was referred to our institution for a second opinion regarding his medical treatment. He presented to his gastroenterologist with an acute flare-up and bloody diarrhea that was not responding to medical treatment that included steroid therapy. While he was undergoing evaluations, his condition worsened, and he developed severe retching, vomiting, and diarrhea. After a protracted vomiting episode, he developed subcutaneous emphysema in the head and neck areas that subsequently extended to the chest. Chest radiograph demonstrated massive subcutaneous emphysema as well right apical and anterior mediastinal and posterior mediastinal pneumothoraces.
Despite these findings, our patient was not in respiratory distress and was hemodynamically stable. We were very concerned about these radiographic findings because he had no recent or remote history of blunt trauma to the chest or neck area. Thoracic surgery consultation was obtained and computed axial tomography scan (CAT-scan) of the neck and chest areas was recommended. CAT-scan with contrast ionic dye confirmed the radiograph findings and showed a 4-cm linear laceration of the membranous trachea (Figure 1). The distal part of the laceration was approximately 4 cm above the carina and 3 cm above the aortic arch. In addition, anterior and posterior mediastinal pneumothoraces were noted on the CAT-scan (Figure 2).
After reviewing these findings, and in view of the fact that the patient’s respiratory status was stable (noted as normal gas exchange and absence of tachypnea and dyspnea), the thoracic surgery service recommended conservative supportive management of the tracheal laceration that included nonsurgical repair and antibiotic therapy for potential mediatinitis. However, his condition worsened, and he developed toxic megacolon from ulcerative colitis. An urgent colectomy was scheduled to prevent colonic rupture and overwhelming sepsis.
The patient was taken to the operating room urgently for colectomy. Before the induction of anesthesia, standard monitors and arterial line were placed. After breathing oxygen, 150 µg of fentanyl, 300 mg of thiopental, 3 mg of d-tubocurarine, and 160 mg of succinylcholine were administered IV. Direct laryngoscopy was performed followed by bronchoscopy and esophagoscopy. Ventilation with 100% oxygen was achieved through the side port of the bronchoscope, and endotracheal intubation was performed before esophagoscopy was performed. These tests confirmed the membranous tracheal laceration without further extension. Diffuse candida esophagitis was also noted. Intubation of the trachea with a size 7.0 endotracheal tube was facilitated under direct vision via fiberoptic bronchoscope. The tracheal cuff was insufflated carefully, assuring that it was positioned distal to the laceration. Anesthesia was maintained with isoflurane, oxygen, and rocuronium. Nitrous oxide was not administered during surgery. Volume-controlled ventilation with a tidal volume of 500 mL and a rate of 8 breaths/min was instituted. At these settings, the peak inspiratory pressure was approximatley 20 cm H2O and did not change throughout the surgery. The patient was hemodynamically stable during surgery and had an uneventful emergence from anesthesia. He was tracheally extubated in the operating room after laryngeal reflexes were demonstrated. Ondansetron 4 mg and droperidol 0.625 mg were administered as prophylaxis against nausea and vomiting. Postoperatively, he was stable in the postanesthesia care unit on room air. He required morphine sulfate for pain relief in the postoperative period. Chest radiograph in postanesthesia care unit revealed no change in pneumothorax and pneumomediastinum. He had an uneventful recovery from surgery. Bronchoscopy a few days later showed a well sealed tracheal mucosa laceration. The pneumothorax and pneumomediastinum resolved spontaneously without the need for tube thoracostomy. One week later, the patient was discharged home in satisfactory condition.
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Discussion
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We described membranous tracheal laceration after episodes of severe vomiting with subsequent development of pneumothorax and pneumomediastinum in a patient who required an urgent colectomy for toxic megacolon under general anesthesia. The laceration and the pneumothoraces were being managed conservatively without primary repair or tube thoracostomy.
Membranous tracheal laceration resulting from severe vomiting is very rare. Increased intrathoracic and intraabdominal pressures produced during the Valsalva maneuver and the weakness of the membranous trachea may have been responsible for the laceration reported in our case. Our patient was also receiving long-term steroid therapy, and this may be a contributing factor to the weakness of the tracheal wall. Patients with a tracheobronchial laceration may be asymptomatic or have various degrees of respiratory distress and hemodynamic compromise. Signs and symptoms of tracheobronchial disruption include dyspnea, massive subcutaneous emphysema, persistent pneumothorax, impaired ventilation and hemodynamics, and persistent air leak after tube thoracostomy. Subtle signs, such as coughing and chest pain, may be present and can be the only indication of a significant injury (8).
Blunt and penetrating trauma are the leading causes of tracheal disruption (9). These injuries are often fatal as a result of their consequences on ventilation unless the patient is rapidly transported to an institution that is equipped to manage this type of injury. Endotracheal intubation may also result in tracheal disruption. Factors that contribute to this complication include the use of styletted tube, placement of a double-lumen endotracheal tube, over-insufflation of the cuff, and attempts at endotracheal intubation by inexperienced personnel. This complication has been reported to be more frequent if the airway management is difficult as a result of anatomical reasons or an emergency situation (10).
The management of anesthesia and ventilation in patients with tracheal disruption is a challenge to the anesthesiologist. The endotracheal tube has to be positioned distally to the laceration in the trachea or in one main stem bronchus. High-frequency jet ventilation may also be used via small-bore catheters located above the laceration or endobronchially (11). The laceration can be repaired surgically or conservative management may be considered, depending on its extent. Nonoperative and conservative management of tracheal laceration was chosen in our case because our patient had stable vital signs, no respiratory distress, and no mediastinal fluid collection.
Anesthetic management of our patient was challenging in part because the of the decision to manage the tracheal laceration conservatively without primary repair. Also, a decision was made not to place a thoracostomy tube, but rather to monitor closely signs of increasing intrathoracic pressure during surgery, such as high airway pressure, hemodynamic compromise, and signs of pulmonary decompensation. Endotracheal intubation may be hazardous under these conditions, because there is a risk of creating a false passage and complete obstruction of the airway potentially resulting in morbidity and mortality (12). We first determined the location and the extent of the laceration during bronchoscopy after the induction of general anesthesia. We chose general anesthesia instead of deep sedation or an inhaled induction of anesthesia in order to avoid movement, coughing, and gagging that usually accompany spontaneous respiration. In addition, both an otorhinolaryngology surgeon and a thoracic surgeon were standing by in case of failed attempts at intubation as a result of complete transection of the trachea resulting in obstruction of the airway or if surgical repair of the laceration had become necessary. Our patient was hemodynamically stable during surgery. Because of the precise positioning of the endotracheal tube cuff, we were able to use positive pressure mode of ventilation, despite the presence of pneumothorax and pneumomediastinum without an increase in peak inspiratory pressure.
In conclusion, tracheal disruption after vomiting resulting in pneumothorax and pneumomediastinum may represent a challenge for the anesthesiologist. We described conservative management of a patient with this grave condition who underwent uneventful general anesthesia for emergency colectomy. Tracheal disruption should be suspected in the presence of emphysema of the neck or mediastinal pneumothorax. Although nonspecific, these signs provide presumptive evidence of tracheobronchial injury that can then be confirmed by bronchoscopy. Some situations, such as that present in our patient, can be managed conservatively, but extensive lacerations may require urgent surgical repair. Without early assessment and immediate recognition, lethal events can occur.
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References
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Accepted for publication June 27, 2000.
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Abstract
Introduction
