Anesth Analg 2004;98:1807-1808
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000117144.16826.61
GENERAL ARTICLES
A Severe Complication After Laser-Induced Damage to a Transtracheal Catheter During Endoscopic Laryngeal Microsurgery
Bettina Leemann, MD*,
Thomas Heidegger, MD*,
Rudolf Grossenbacher, MD
,
Thomas Schnider, MD*, and
Hans J. Gerig, MD*
Departments of *Anesthesiology and
Ear, Nose, Throat, Head, and Neck Surgery, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
Address correspondence and reprint requests to Bettina Leemann, MD, Department of Anesthesiology, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, 9007 St. Gallen, Switzerland. Address e-mail to bettina.leemann{at}kssg.ch
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Abstract
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Subcutaneous emphysema and pneumothorax is a rare and severe complication of percutaneous transtracheal jet ventilation, usually caused by obstruction of the upper airway or displacement of the tracheal catheter. Nevertheless, it is our preferred technique for endoscopic laryngeal laser surgery. We report a patient with acute subcutaneous emphysema and pneumothorax during laser surgery, caused by unobserved laser damage and discuss the associated risk factors.
IMPLICATIONS: The percutaneous transtracheal jet ventilation for elective laryngeal laser surgery reduces the risk of airway fires and gives a free endoscopic operative field. This case report suggests that, even when using a teflon catheter, laser-induced damage with severe complications might occur.
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Introduction
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High frequency jet ventilation (HFJV) through a transtracheal catheter (TTC) is a method that has proven reliable for artificial ventilation of patients who have undergone laser surgery of the glottis (1–4). Moreover, the use of a teflon TTC minimizes the risk of laser-induced endotracheal fire (5). We present a case with an acute extensive subcutaneous emphysema and concomitant pneumothorax caused by a hole in the TTC during carbon dioxide laser (CO2 laser) surgery.
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Case Report
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Laser cordectomy was planned for a 62-yr-old male patient (67 kg, 167 cm). Hoarseness, which had been present for 2 mo, led to the diagnosis of a carcinoma of the right vocal cord. Apart from heavy cigarette consumption, the cardiopulmonary history was unremarkable and we decided not to do any further investigations. The patient received premedication with 0.15 mg of clonidine orally, 90 min before the beginning of the operation. Usual monitoring was used. Anesthesia was induced with 130 mg of propofol IV, 0.15 mg of fentanyl IV, and 40 mg of rocuronium IV and maintained with propofol, fentanyl, and rocuronium. The 13-gauge TTC (VBM Medizintechnik, Sulz, Germany) was positioned under fiberoptic assistance without problems (6). The lungs were ventilated with an AMS 1000TM jet ventilator (Acutronic Medical Systems AG, Hirzel, Switzerland) with a frequency of 150/min, inspiration/expiration ratio of 0.5, and ventilation pressure of 2.3 atm. At the beginning of the laser operation (Ultrapulse 2000L; Coherent Inc., Santa Clara, CA) the inspiratory oxygen fraction was reduced to 0.4. Excision of the tumor, which extended into the subglottic region, was then begun with continuous laser technique using 5–10 W. To improve visibility, the surgeon had to manipulate the larynx several times externally, which intermittently interrupted the HFJV. Suddenly, the anesthesiologist realized that subcutaneous emphysema had already spread to the neck and the thorax. HFJV was immediately stopped. The patient then was ventilated without problems through a rigid endoscope, which was introduced by the surgeon to confirm the correct positioning of the TTC. Bronchoscopy revealed no abnormal features. Because the reason for the incident remained unclear, the operation was discontinued after 60 min, even though there was a residual tumor floating into the trachea. The trachea then was intubated orally, and the TTC was left in situ, considering the necessary second operation. Circulation and oxygenation were not impaired in any phase. On the chest radiograph, the suspicion of a pneumothorax on the left side requiring drainage was confirmed. In addition, a small pneumothorax on the right side was shown, as well as mediastinal emphysema with a slight shift to the left. The subcutaneous emphysema regressed completely within a few hours.
On the following day, the remaining parts of the tumor were resected. Laryngoscopy with the indwelling tube presented a glottis that could be brought into focus without difficulty. To inspect the trachea, the tube was removed and exchanged for a 6-mm ventilation bronchoscope which revealed a correctly situated TTC and no airway lesions. Therefore, it was decided to start jet ventilation via the TTC carefully, with only 0.5 atm. After activating the jet only for a few seconds, subcutaneous emphysema again occurred. The HFJV was immediately stopped and the trachea was intubated with a Laser-FlexTM tube (Mallinkrodt Medical, Athlone, Ireland). The residual tumor was then resected in toto without difficulty. The TTC was removed and, to our great surprise, a hole with manifestations of melting effects (Fig. 1) was revealed in the upper lateral wall approximately 15 mm distal to the fixing plate.
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Discussion
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HFJV via TTC is regarded as especially suitable for diagnostic microlaryngoscopy and laser surgery in otorhinolaryngology. The surgeon has an excellent view over the area of surgery, and the danger of fire is reduced (1–4,7–9). We have used this method routinely for >6 years (6).
The most frequent complication of endolaryngeal CO2 laser surgery is ignition of the gas mixture within the airway with involvement of the endotracheal tube (5,10–12). This accident is caused by the high temperature of the laser, which acts on tissue or on tissue particles. The danger increases when combustible material is present in the airway (including the endotracheal tubes), when a gas mixture with a large content of oxygen is used, or if there is continuous or protracted use of a high-energy laser (5,10,11). Teflon showed the largest resistance concerning ignition characteristics, if it was exposed to the CO2 laser beams (5,12).
After removing the TTC from the trachea, we discovered a hole on the side with marginal melting effects 15 mm distal to the fixing plate. The possibility of laser-induced damage to a teflon TTC has already been described, but without an explanation as to the way it happened (3). In our case, the ventral subglottic spreading of the tumor caused the impact of the laser on the TTC. It is suspected that the hole might have been secondarily displaced under the mucosa of the trachea and the leakage of gas into the surrounding tissue led to paratracheal dissection of the fascial plain with emphysema typically on the neck and pneumomediastinum. The shift was facilitated by the manipulations at the neck despite correct mounting of the cannula (1,2). We conclude therefore that the pneumothorax was a result of paratracheal air spread and not in consequence of outlet obstruction and alveolar rupture, as intraoperatively supposed. The continuous monitoring of the end-expiratory pressure could not prevent this problem, because the lateral hole in the cannula did not impair the HFJV (3,8,13). Only the clinical observation of the subcutaneous emphysema led to a rapid intervention.
In conclusion, this case shows that a ventral subglottic tumor can increase the risk of laser-induced lesion of the TTC. Manipulations of the larynx increase the danger of dislocating the TTC. Besides continuous monitoring of the end-expiratory pressure, there must be continuous clinical surveillance of HFJV.
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Accepted for publication December 18, 2003.
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Should CO2 Laser Jet Ventilation Be Abandoned? * Response
Anesth. Analg.,
December 1, 2004;
99(6):
1882 - 1882.
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Abstract
Introduction
